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Full text of "Active projects"

Active Projects 



Research and Demonstrations in Health Care F 1 




Contents 



37 

91 

185 

193 
195 

205 
209 
211 




Theme 1: Monitoring and Evaluating Health 
System Performance: Access, Quality, Program 
Erriciency ana Costs 

Theme 2: Improving' Health Care Financing" 
ana Delivery Mechanisms: Current Prog'rams 
and New Models 

Theme 3: Meeting the Needs or 
Vulnerable Populations 

Theme 4: Inlormation to Improve 
Consumer Choice and Health status 

Master Contracts and Research Centers 

Task Order Contracts 

^mall Business Innovation Research 

Dissertation Fellowship Grants 

Indices: 

Topical Index 

Alphabetical Index oj Research and 

Demonstration Projects 
Awardee Organizations 

Principal Investigators and Project Directors 
Geographic Index of Studies and Demonstrations 
Project Officers and Project Directors 




U. S. Department of Health and 
Human Services 

Donna E. Shalala, Secretary 

Health Care Financing Administration 

Bruce C. Vladeck, Administrator 

Office of Research and Demonstrations 

Barbara S. Cooper, Acting Director 

Thomas A. Gustafson, Ph.D., Deputy Director 

Office of Research and 
Demonstrations Support 

Lillian K. Gibbons, Dr. P.H., Director 

Office of State Health Reform 
Demonstrations 

Lu Zawistowich, Sc.D., Director 

Office of Payment and Delivery 
Research and Demonstrations 

Alfonso D. Esposito, Director 

Office of Beneficiary and Program 
Research and Demonstrations 

Steven B. Clauser, Ph.D., Director 

Dissemination Staff 

Maria A. Friedman, D.B.A., Director 

Financial, Administrative, and 
Procurement Staff 

William D. Saunders, J.D., Director 



Active Projects Report 



The Orrice oi Research and Demonstrations (ORD), oi the Health 
Care Financing Administration (HLFA), directs more than 400 
research, demonstration, and evaluation projects. Many or these projects 
locus on program expend itures as they relate to payment, coverage, 
eligibility and management alternatives under Medicare and Medicaid. 
Research projects also develop and assess methods and approaches related 
to the quality health care, alternative health care delivery systems, 
innovative financing arrangements and cost containment strategies. 
ORD-sponsored studies additionally examine impacts or Medicare and 
Medicaid on beneiiciaries' health status, access to services, utilization, 
and out-oi-pocket expenditures. The behavior and economics or health 
care providers and the overall health care industry also are topics or 
investigations. 

This report covers basic inrormation on projects active irom 
October 1, 1995 through December 31, 1996. Included are intramural 
projects, conducted by ORD stair, and extramural projects, conducted 
by contractors and grantees with ORD support and by other investigators 
outside of ORD. 

The majority ol the project summaries are arranged according to 
ORD's lour research themes, which rellect cross-cutting research 
priorities lor HLFA. They are: Theme 1: Monitoring and Evaluating 
Health System Periormance: Access, Quality, Program Elliciency and 
Costs; Theme 2: Improving Health Care Financing and Delivery 
Mechanisms: Current Programs and New Models; Theme 3: Meeting 
the Needs ol Vulnerable Populations; and Theme 4: Inrormation to 
Improve Consumer Choice and Health Status. Separate project 
summaries are provided lor research sponsored under the Small Business 
Innovation Research Program and the Dissertation Fellowship Grant 
Program. General descriptions are given lor research conducted under 
ORD's Master Contracts and Research Centers and Task Order 
Contracts. Several indices are provided to help readers identity speciiic 
projects, principal investigators, awardee organizations and project 
olricers. 

The synopsis ol each project includes an identification number, project 
title, project number, project period, name ol principal investigator, 
and the name and address or its awardee, contractor or grantee 
organization. Also included is the name oi the Federal project orricer 
with primary responsibility for the project, the Federal statute under 
which it was conducted (if applicable), the status ol the project as oi 
December 31, 1996, and a brief description oi each project's goals and 
iindings. 

This is the seventeenth edition or tne Active Projects Report (iormerly 
the Status Report). Updated editions are produced on an annual basis. 



3*3 

73 

r? 



Acknowledgments 

Several persons contributed to the successful 
completion of this edition of the Active Projects 
Report — Gloria Smiddy of the Office of State 
Health Reform Demonstrations; Sherry Terrell, 
Ph.D., of the Division of Delivery Systems and 
Financing; William J. Sobaski of the Division of 
Payment Systems; Florence Beckman and Nancy 
Miller of the Division of Aging and Disability; 



Sam McNeill of the Division of Data Systems 
Support; Cheryl Hickman of the Division of Health 
Information and Outcomes provided extensive 
support in production management. Joyce Brown, 
Naomi Bundy, Doris Hall, and Edward Olshaker of 
the Dissemination Staff provided support in 
editorial and printing management. 



Theme 1 : Monitoring and Evaluating Health System 
Performance: Access, Quality, Program Efficiency and Costs 



Extramural 

96-060 A Framework of Cross-Sectional and 
Longitudinal Issues for Analysis in the 
Medicare Beneficiary Health Status Registry 



Project No. 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



360-96-90100 
September 1996— January 
$ 25,000 
Task Order 



!997 



Barry Bye 

Barry Bye 

301 North Beauregard Street 

Alexandria, VA 22312 

Carolyn Rimes 

Division of Aging and Disability 



Description: This project will identify analytical and 
methodological issues for longitudinal panel analysis. 
Topics will be assessed, and a framework incorporating 
longitudinal and cross-sectional methods will be 
developed for the Medicare Beneficiary Health Status 
Registry. This will include trends, cohort and time-series 
methods. A report will be prepared discussing the 
Registry's database, including the administrative data. 
Also included will be specific recommendations for both 
cross-sectional and longitudinal analysis projects and 
papers. 

Status: The project has been initiated and topics for 
longitudinal and cross-sectional analysis have been 
identified. 

95-095 Access in Managed-Care Plans 

Project No.: 500-95-0048/TO2 

Period: September 1995-March 1997 

Funding: $401,389 

Award: Task Order in Basic Order Contract 

Principal 

Investigator: Margo L. Rosenbach, Ph.D. and 

Debra Dayhoff 
Awardee: Health Economics Research, Inc. 

(Seepage 198) 
HCFA Project Renee Mentnech 
Officer: Division of Delivery Systems and 

Financing 

Description: The purpose of this project is to develop a 
framework for measuring access in managed care using 



encounter level data. This framework will then be tested 
with actual data from the Harvard Community Health Plan 
in Boston. 

Status: The contractor conducted a literature review and 
presented a proposed design at the first technical expert 
panel (TEP) meeting in January 1996. The design was 
revised and accepted by the TEP. Preliminary results for 
the first two measures — mammography use among elderly 
females and retinal screening of diabetics — have been 
generated. A "lessons learned" document was drafted that 
describes the difficulties the principal investigators 
confronted in generating the rates from encounter data. 
The remaining measures for managed-care plans are being 
generated along with comparable measures for the fee-for- 
service sector in the same market area. 

92-095 Access to Medicare Physician Services 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandate: 



17-C-90044/3 
March 1992-June 1996 
$ 710,421 
Cooperative Agreement 

Stephen Zuckerman, Ph.D. 

Urban Institute 

2100 M Street, NW. 

Washington, DC 20037 

Paul W. Eggers, Ph.D. 

Division of Health Information and 

Outcomes 

Omnibus Budget Reconciliation Act of 
1989 (Public Law 101-239) 



Description: This cooperative agreement comprises three 
tasks related to Medicare beneficiary access to physician 
services. Task 1 involves measuring trends in the volume 
and intensity of Medicare physician services. Task 2 
involves econometric analysis of the relationship between 
pricing policies and the growth in the volume of Medicare 
physician services for the years 1986 through 1992. Task 3 
uses the 1992 Medicare Current Beneficiary Survey 
(MCBS) to study beneficiary access to physician services. 

Status: Analyses under Task 1 (i.e., tracking changes in 
the volume and intensity of physician services between 
1986 and 1994 using relative value units) and Task 2 have 
been completed. Results from Task 1 show that volume 
and intensity growth slowed considerably relative to 
historical trends during the first 2 years under the 



Theme 1 : Monitoring and Evaluating Health System Performance 



Medicare fee schedule. However, between 1993 and 1994, 
volume and intensity growth rebounded to rates close to 
those in the period prior to the fee schedule. 
Task 2 shows that there appears to be an inverse 
relationship between price and volume and intensity 
changes during the years 1986 through 1992, but that the 
strength of the relationship varies across specialties, types 
of services, and years. Draft reports for both Tasks 1 and 
2 have been delivered to the Health Care Financing 
Administration. The analysis of access using the MCBS 
under Task 3 is near completion. The models have been 
estimated and the draft report is being prepared. A final 
report is expected by the end of calendar year 1996. 

96-002 ADP Services Supporting Research 
and Demonstration Activities: Master Contract: 
CHD Research Associates, Inc. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0516 

September 1 996— September 1997 

Task Order Contract 

Celia H. Dahlman 

CHD Research Associates, Inc. 

5515 Twin Knolls Road #322 

Columbia, MD 21045 

Alan W. Bradt 

Division of Data Systems Resources 



Description: The contractor will provide programming, 
analytical, and statistical application skills in support of 
research activities for the Office of Research and 
Demonstrations. The initial contract is for 1 year with 
4 option years. 

Status: The task order contract was awarded in 
September 1996. The awardee is able to compete for 
individual task orders until September 2001. The first two 
task orders were awarded concurrently with the base 
contract. The total value of the first two tasks is 
S246,542.00. The individual tasks awarded for this 
contract are identifiers 96-049 and 96-050. 

96-049 ADP Services Supporting Research 
and Demonstration Activities: Task Order: 
CHD Research Associates, Inc. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



500-96-0516-0001 
September 1996—January 1997 
Task Order 

Celia H. Dahlman 
CHD Research Associates, Inc. 
5515 Twin Knolls Road #322 
Columbia, MD 21045 



HCFA Project Alan W. Bradt 

Officer: Division of Data Systems Resources 

Description: The contractor will provide programming, 
analytical, and statistical application skills in support of 
research activities for the Office of Research and 
Demonstrations. The awardee will explore and tabulate 
data from the National Employer Health Insurance Survey 
(NEHIS) establishment. In addition, the awardee will 
produce basic descriptive data on private health 
insurance. These data will provide the basis of private 
health insurance within the national and State health 
accounts. 

Status: The task order contract was awarded in 
September 1996 and is to be completed by January 31, 
1997. This awardee is able to compete for other individual 
task orders until September 2001. The task order, contract 
number 500-96-0517-0001, was awarded concurrently 
with the base contract. The total value of this task is 
$48,589.00. The base contract is identifier 96-002. The 
second task order is identifier 96-050. 

96-050 ADP Services Supporting Research 
and Demonstration Activities: Task Order: 
CHD Research Associates, Inc. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0516-0002 
September 1996-August 1997 
Task Order 

Celia H. Dahlman 

CHD Research Associates, Inc. 

5515 Twin Knolls Road #322 

Columbia, MD 21045 

Alan W. Bradt 

Division of Data Systems Resources 



Description: The contractor will provide programming, 
analytical, and statistical application skills in support of 
research activities for the Office of Research and 
Demonstrations. This task is to produce reports of the 
epidemiology of influenza and pneumococcal vaccination 
by State and the Nation. 

Status: The task order contract was awarded in September 
1996 and is to be completed by August 31, 1997. This 
awardee is able to compete for other individual task orders 
until September 2001. The task order 500-96-0517-0002 
was awarded concurrently with the base contract. The 
total value of this task is $197,944.00. The base contract 
is identifier 96-002. The first task order is identifier 
96-049. 



Theme 1 : Monitoring and Evaluating Health System Performance 



96-003 ADP Services Supporting Research 
and Demonstration Activities: Master Contract: 
Jing Xing Health and Safety, Inc. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0026 

September 1996-September 1997 . 

Master Contract 

George Kowalczyk 

Jing Xing Health and Safety, Inc. 

7008-K Little River Turnpike 

Annandale, VA 22003 

Alan W. Bradt 

Division of Data Systems Resources 



Description: The contractor will provide programming, 
analytical, and statistical application skills in support of 
research activities for the Office of Research and 
Demonstrations. The initial contract is for 1 year with 
4 option years. 

Status: The master contract was awarded in 
September 1996. This awardee is able to compete for 
individual task orders until September 2001. The first 
four task orders were awarded concurrently with the base 
contract. The total value of the first four tasks is 
$368,246. The individual tasks awarded are identifiers 
96-051, 96-052, 96-053, and 96-054. 

96-066 Analysis of Methodological Aspects of the 
Medicare Beneficiary Health Status Registry 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



360-96-90070 
September 1996— December 
$ 10,000 
Purchase Order 



996 



HCFA Project 
Officer: 



Judith Ann Kasper, Ph.D. 
Johns Hopkins School of 
Hygiene and Public Health 
Department of Health Policy and 
Management 

624 North Broadway Street 
Room 639, Hampton House 
Baltimore, MD 21205-1901 
Marsha G. Davenport, M.D., MPH 
Division of Health Information and 
Outcomes 



Description: The purpose of this project is to examine the 
extent to which the proposed Medicare Beneficiary Health 
Status Registry (Registry) might be integrated with 
existing surveys. The contractor will develop a frame- 
work for identifying and evaluating issues related to 
integration. Such issues to be examined include: 

• Consistency of questions across surveys. 

• Sample size implications. 



• Survey design comparisons. 

• Analytic capabilities. 

• Program goals. 

In addition, the questionnaires proposed for the Registry 
will be critically reviewed and recommendations for 
improvements will be submitted. Further, methodological 
issues (such as mode effects) related to the data collection 
technique will be reviewed and discussed. 

Status: This project is ongoing. 

96-053 Analysis of Patterns of Payment, 
Users and Payment Per User for Disabled 
Medicaid Enrollees by Age Group: Task Order: 
Jing Xing Health and Safety, Inc. 



Project No. 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0026-0003 
September 1996-January 1997 
$ 16,073 
Task Order 

George Kowalczyk 

Jing Xing Health and Safety, Inc. 

7008-K Little River Turnpike 

Annandale, VA 22003 

Alan W. Bradt 

Division of Data Systems Resources 



Description: The contractor will provide programming, 
analytical, and statistical application skills in support of 
research activities for the Office of Research and 
Demonstrations. This task order will use State Medicaid 
Research Files data to produce basic descriptive data on 
payments, user, and payments on selected Medicaid 
services by age group. 

Status: The task order contract was awarded in 
September 1996, concurrently with the base contract. 
Delivery is expected in January 1997. The total value of 
this task is $16,073. The base contract is identifier 
96-003. Other tasks are identifiers 96-051, 96-052, 
and 96-054. 

96-059 Analysis of Sampling and Design Issues for 
the Medicare Beneficiary Health Status Registry 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



360-96-90090 

September 1 996-February 1997 

$ 25,000 

Task Order 

James Beebe 
James Beebe 
1345 Tydings Road 
Annapolis, MD 2140 



Theme 1 : Monitoring and Evaluating Health System Performance 



HCFA Project Carolyn Rimes 

Officer: Division of Aging and Disability 

Description: This project will assess and evaluate 
sampling proposed for the Medicare Beneficiary Health 
Status Registry. A framework will be developed to 
evaluate the sampling, weighting, initialization of the 
sample, imputations and methods for estimation. This 
framework will be used to evaluate the proposed sampling 
frame on the collection of statewide information. A report 
will be prepared recommending: sampling frame 
refinements, design aspects requiring refinement prior to 
fielding the survey, and timeframes and methods for 
monitoring the reliability of the sample and assessing 
response rates. 

Status: The project has been initiated and a preliminary 
outline and assessment of the sampling frame is under 
development. 

94-072 Analysis of the Validity of the Discretionary 
Component of Diagnostic-Cost-Group Risk Adjusters 



95-010 Assessment of the Impact of 
Pharmacy Benefit Managers 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



17-C-90295/1 

September 1994-February 1996 

$ 97,341 

Cooperative Agreement 

Frank W. Porell, Ph.D. 
DataChron Health Systems, Inc. 
763 Massachusetts Avenue, Suite 7 
Cambridge, MA 02139 
Michael Kendix, Ph.D. 
Division of Health Information and 
Outcomes 



Description: The study investigates the validity of the 
discretionary component of the diagnostic-cost-group 
(DCG) risk-classification system and three -other methods 
for distinguishing discretionary and non-discretionary 
diagnoses. This entails an assessment of the extent to 
which the differences among health maintenance 
organizations, fee-for-service providers, and geographic 
variations in hospital admission rates can be associated 
with variations in rates of discretionary hospital 
admissions. In addition, this study examines the 
relationship between the aggregate rate of non- 
discretionary admissions and mortality rates. The 
empirical performance of the DCG discretionary ratings, 
in this regard, is compared with the performance of 
several alternative classifications of discretionary 
admissions. 

Status: A second 6-month, no-cost extension has been 
granted. 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



95-023/PK 

July 1995-June 1996 

$ 213,165 
Contract 

David Zimmerman, Ph.D. 
University of Wisconsin 
610 Walnut Street 
Madison, WI 53705-2397 
Kathleen Gondek, Ph.D. 
Division of Payment Systems 



Description: The growth of managed purchasing of 
pharmaceuticals has risen dramatically. Today, managed 
purchasers include health maintenance organizations, 
various buying consortia of independent and/or chain 
pharmacies, and pharmacy benefits managers (PBMs). 
PBMs represent one type of provider with considerable 
purchasing power. They are responsible for the design, 
implementation, and administration of pharmacy benefits 
programs, largely through managed-care organizations 
(MCOs), major manufacturers, and union groups. 

The project will cover two general areas — comparison of 
cost and quality issues for drug benefits among Medicaid 
fee-for-service, Medicaid managed care, and PBM non- 
Medicaid models, and potential impact of PBMs on the 
system. A comprehensive literature review will provide 
background and suggest a typology of PBMs, 
incorporating such variables as organization, growth, 
scope of service, and clients. To examine cost and quality 
issues, information will be collected using a case study 
approach directly from State Medicaid programs, MCOs 
that enroll Medicaid recipients and subcontract with 
PBMs, and PBMs. 

Status: This project has been completed. The final report 
may be obtained through the National Technical 
Information Service at (703) 487-4650, accession number, 
PB97-103683. 

92-093 Characteristics and Outcomes of Persons 
Screened into Connecticut's 2176 Program 

(Formerly, Long-Term Care Studies (Section 207)) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



500-89-0047/34 
June 1992— November 
$ 132,400 
Contract 

David Kennel 1 
Lewin/VHI, Inc. 
(See page 17) 



994 



Theme 1: Monitoring and Evaluating Health System Performance 



HCFA Project Carolyn Rimes 

Officer: Division of Aging and Disability 

Description: In recent years, a major focus of research on 
home- and community-based care (HCBC) has been on 
the number of persons who would be eligible for services 
based on dependencies in activities of daily living 
(ADLs). While previous researchers have estimated the 
size of beneficiary populations under different eligibility 
standards, little is known about the number of eligibles 
who would actually participate in HCBC programs. This 
project examines why 20 percent of persons meeting ADL 
requirements for eligibility did not participate in the 
Medicaid 2176 program in Connecticut. The subsequent 
use of long-term-care services by these nonparticipants is 
compared to the use of services by participants in the 
Connecticut Medicaid 2176 program. 

Status: This project has been completed. Findings from 
the study have been published as part of the conference 
proceedings from the Brookings Institute. The publica- 
tion, Persons with Disabilities, is available from the 
Brookings Institute. 

92-092 Combining Formal and Informal Care in 
Serving Frail Elderly People (Formerly, Long-Term 
Care Studies (Section 207) 

Project No.: 500-89-0047/35 

Period: June 1 992-December 1995 

Funding: $ 93,700 

Award: Contract 

Principal 

Investigator: David Kennell 

Awardee: Lewin/VHI, Inc. 

(See page 17) 

HCFA Project Carolyn Rimes 

Officer: Division of Aging and Disability 

Description: The purpose of this study is to determine 
whether formal care substitutes for or complements 
informal care. To determine the relationship between 
formal care and informal care, a data set generated by the 
case-management agency, Connecticut Community Care, 
Inc., (CCCI) is analyzed. CCCI conducts patient 
assessments of all publicly supported long-term-care 
patients in Connecticut. This data set offers a unique 
opportunity to conduct an in-depth longitudinal analysis 
of the effect of providing formal care on the provision of 
informal care for a large population of elderly persons. 
Although surveys have repeatedly found that older 
persons strongly prefer community services to services 
offered in nursing homes, policymakers have resisted a 
major expansion of home-care services even though 



community services are usually less expensive than 
nursing home services. The most important reason for this 
resistance is the fear that a publicly funded home-care 
program will encourage family caregivers of the elderly to 
substitute formal care for informal care. 

Status: This project is complete and is published in the 
proceedings from the Brooking 's Conference, Persons 
with Disabilities. This publication is available from the 
Brookings Institute. 

94-038 Community Nursing Organization 
Demonstration External Quality Assurance 

Project No.: 500-92-00 14DO04 

Period: July 1994-July 1997 

Funding: $ 535,304 

Award: Delivery Order in Master Contract 

Principal 

Investigator: David Kidder, Ph.D. 

Awardee: Abt Associates, Inc. 

(See page 64) 

HCFA Project Melissa Hulbert, MPS 

Officer: Division of Aging and Disability 

Mandate: Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 

Description: The purpose of the Community Nursing 
Organization (CNO) Demonstration External Quality 
Assurance project is to conduct an external review of the 
quality of health care delivered to Medicare beneficiaries 
participating in the CNO demonstration (a risk- 
reimbursed coordinated-care program for home health 
and selected ambulatory services). The CNO 
Demonstration External Quality Assurance project 
includes a quarterly review of client medical records for a 
sample of clients receiving Medicare-covered mandatory 
CNO services, and a quarterly review of CNO assessments 
and provision of CNO interventions on a sample of all 
enrollees. Under this project, the awardee will be 
responsible for monitoring the quality of care 
management and health education services provided 
through the CNO and implementing corrective actions, 
when necessary. The quality of traditional Medicare home 
health services will be monitored. The awardee also will 
conduct a use review of the home health services provided 
to enrollees to validate or support changes in capitation 
payment rates. The evaluation contractor will be provided 
with accurate and complete documentation of the findings 
and interventions of the quality assurance process. 

Status: The developmental phase of the project has been 
completed, and quality reviews are being conducted. 



Theme 1 : Monitoring and Evaluating Health System Performance 



96-051 Comparison of Enrollment Characteristics, 
Utilization and Expenditures for Medicaid and 
Federal Employees Blue Cross Blue Shield 
Populations: Task Order: Jing Xing Health 
and Safety, Inc. 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0026-0001 
September 1 996-November 1997 
S 132,778 
Task Order 

George Kowalczyk 

Jing Xing Health and Safety, Inc. 

7008-K Little River Turnpike 

Annandale, VA 22003 

Alan W. Bradt 

Division of Data Systems Resources 



Description: The contractor will provide programming, 
analytical, and statistical application skills in support of 
research activities for the Office of Research and 
Demonstrations. The awardee will provide files, 
programs, and analysis for a comparison of enrollment 
characteristics, utilization, and expenditures between 
Medicaid and Federal Blue Cross and Blue Shield 
Populations, for the period 1989-93. 

Status: The task order contract was awarded in September 
1996, concurrently with the base contract. The delivery 
date is November 29, 1997. The total value of this first 
task is S132,778. The base contract is identifier 96-003. 
Other tasks are identifiers 96-052, 96-053, and 96-054. 

96-01 1 Comparison of Pharmaceutical Quality of Care 
for Pediatric Asthma Across Medicaid Populations: 
Task Order: University of Alabama at Birmingham 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0013 
August 1996-July 1998 
$ 300,298 
Task Order 

Janet Bronstein, Ph.D. 

Lister Hill Center for Health Policy 

University of Alabama at Birmingham 

1825 University Boulevard 

MJH B23 

Birmingham, AL 35294-2010 

Leslye Fitterman, Ph.D. 

Division of Health Information and 

Outcomes 



Description: This project will examine quality of care in 
the provision of health services to treat asthma in 
Medicaid children in two States, Alabama and Michigan. 
Specifically, it will determine the extent of prescribing 
problems for pediatric asthma in these Medicaid 



programs, and will assess the economic and utilization 
costs of these problems. To address these research 
questions, the investigators will test the validity of claims 
data to assess physician prescribing problems and 
simulate the potential impact of a retrospective drug 
utilization review system. 

Status: The project has begun with the acquisition of the 
claims data. 

93-092 Costs of Medicare Skilled Nursing Facility 
Therapy Services (Formerly, Long-Term Care Studies 
(Section 207)) 

Project No.: 500-89-0047/41 

Period: July 1993-December 1994 

Funding: $ 160,800 

Award: Contract 

Principal 

Investigator: David Kennell 

Awardee: Lewin/VHI, Inc. 

(See page 17) 

HCFA Project Carolyn Rimes 

Officer: Division of Aging and Disability 

Description: Approximately two-thirds of all Medicare 
skilled nursing facility (SNF) stays involve physical, 
occupational, or speech therapy. The importance of 
therapy services to the Medicare SNF benefit suggests that 
changes over time in charges for this service, as well as 
the patterns of charges between Part A and Part B, need to 
be tracked. This study employs Medicare provider 
analysis and reviews SNF data to examine the 
characteristics of patients who receive high and very high- 
intensity therapy services. It also analyzes episodes of 
illness of Medicare patients who experience a SNF stay to 
elucidate the relationship between SNF use and providers 
of Medicare services. 

Status: A draft report has been received. The final report 
is expected to be completed by December 1996. 

92-007 Data for Hospital Cost Monitoring and 
Analysis of Hospital Costs 



Project No.: 


500-92-0003 


Period: 


January 1992— December 1996 


Funding: 


$ 715,700 


Award: 


Contract 


Awardee: 


American Hospital Association 




840 North Lake Shore Drive 




Chicago, IL 60611 


HCFA Project 


Benson L. Dutton 


Officer: 


Division of Payment Systems 



Mandate: 1983 Amendment to the Social Security 

Act (Public Law 98-21) 



Theme 1: Monitoring and Evaluating Health System Performance 



Description: The American Hospital Association (AHA) 
collects data on hospitals with the Annual Survey of 
Hospitals, and the National Monthly Hospital Panel 
Survey. The Annual Survey of Hospitals database consists 
of the following files: the AHA annual survey expanded 
data file; the modified Federal information pro?essing 
system (FIPS) county codes and names file; the full FIPS 
county codes and names file; metropolitan statistical area 
codes and names file; the data file layout file; the COBOL 
data file description; the SAS data file description; the 
health care system layout file; and the health care system 
data file. The monthly hospital panel survey collects 
information on: hospital beds and bassinets; inpatient and 
outpatient utilization; revenue, expenses, and current 
assets and liabilities; personnel; and inpatient utilization 
for beneficiaries 65 years of age and over. The national 
hospital panel output data along with other 
documentation are delivered quarterly as data cartridge 
tapes, micro-floppy disks, and printed tables. The Annual 
Survey of Hospitals data are delivered annually in 
December for the preceding year in the data cartridge tape 
format only. 

Status: The monthly National Hospital Panel Survey 
Reports and the monthly Hospital Statistics through 
March 1996 have been delivered. The Annual Survey 
of Hospitals for fiscal year 1995 is expected in 
December 1996. 

95-061 Demonstration of Integrated Care 
Management Systems for High-Cost/High-Risk 
Medicaid Beneficiaries 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-0003 5/3-01 
October 1 995-October 2000 
Waiver-only Project 
Grant 

Martin P. Wasserman, M.D., J.D. 

Department of Health and 

Mental Hygiene 

State of Maryland 

201 West Preston Street 

Baltimore, MD 21201 

William D. Clark 

Division of Aging and Disability 



Description: Maryland is testing a new case-management 
delivery system for high-cost/high-risk Medicaid 
beneficiaries and those at risk to become high cost. The 
program seeks to maintain or improve access to providers 
and the quality of the care provided. The demonstration 
also should lower health care costs by reducing hospital 
readmission rates and by maintaining patients in the 
lowest cost medically appropriate setting. The University 
of Maryland at Baltimore County, Center for Health 
Program Development and Management, under contract 



to the State, is responsible for the demonstration's 
operations. 

Status: This project was approved in October 1995. In 
October 1996, the State requested to withdraw the 
waivers, as the project was incorporated in Maryland's 
statewide waiver that was approved in October 1996. 

96-004 Demonstration Project for Family Planning and 
Preventive Reproductive Services, State of Maryland 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00043/3 

October 1 994-September 2000 

Waiver-only Project 

Grant 

Susan Tucker 

Department of Health and 

Mental Hygiene 

State of Maryland 

201 West Preston Street 

Baltimore, MD 21201 

Eleanor Janice Collins 

Division of Health, Information and 

Outcomes 



Description: Under this demonstration project, the State 
of Maryland proposes to extend Medicaid eligibility for 
family planning services to women who are Medicaid- 
eligible because of the pregnancy. These women will 
remain Medicaid-eligible 60-days post-partum (i.e., for 
those women who fall in the pregnant women and 
children eligibility category). Maryland intends to 
demonstrate that covering family planning and preventive 
reproductive services for these women will reduce 
Medicaid payments by reducing the number of unintended 
births and by improving health status through preventive 
care. 

Status: The Department of Health and Mental Hygiene 
staff has: 

• Developed a medical assistance recipient master file. 

• Updated the automated eligibility verification system to 
include information on project participants' eligibility. 

• Developed a list of services to be reimbursed under the 
program. 

• Provided project recipients with identification cards. 

The State of Maryland is in the process of moving to 
Year 03 of this 5-year demonstration project. 

95-026 Design Contract for the Medicare 
Beneficiary Health Status Registry 

Project No.: 500-95-0060 

Period: October 1995-July 1996 

Funding: $ 458,824 



Theme 1 : Monitoring and Evaluating Health System Performance 



Award: 
Principal 
Investigator: 
Awardee: 



HCFA Project 
Officer: 



Contract 

Kirk Pate 

Research Triangle Institute 

P. O. Box 12194 

Research Triangle Park, NC 27709 

Leslye Fitterman, Ph.D. 

Division of Health Information 

and Outcomes 



Description: The purpose of this contract is to develop 
features of a new system entitled, "The Medicare 
Beneficiary Health Status Registry," which is designed to 
monitor and evaluate the health status of Medicare 
beneficiaries throughout their enrollment in the program. 
The Registry' survey will collect information from 
beneficiaries that is not in the administrative claims. The 
Registiy system will link the information to claims and 
provide a longitudinal database for studies to inform 
policy decisions concerning health care coverage, 
payment, financing, and delivery systems. The goals of 
the project encompass three broad areas: a sample design, 
questions to be included in the questionnaires, and survey 
procedures. This project builds upon the findings from the 
Registry pilot study conducted in 1993 that found that 
reliable and accurate information about functional status, 
quality of life, health behaviors, and prior medical history 
can be collected across all age groups in mail question- 
naire with telephone follow-up of non-responders. A 
panel composed of experts in health services research, 
health status measurement, sampling design, and survey 
design worked with Research Triangle Institute to develop 
the plans to implement the Registry survey. The 
recommendations include a sample design and strategy, 
questionnaire contents and format, and survey procedures. 

Status: The recommendations, available from the National 
Technical Information Service, are presented in three 
volumes: 1) Executive Summary of the Recommended 
Design for the Medicare Registry (PB96-216130); 
2) Design Documentation Report for the Medicare 
Registry (PB96-21 61 22); and 3) Appendices: Design 
Documentation Report for the Medicare Registry 
(PB96-216148). 

96-067 Development of a Comprehensive Monitoring 
and Evaluation Initiative for HCFA Programs 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



500-95-0056/2 
October 1995-July 1997 
S 249,359 
Contract 

Joyce Mann 
Rand Corporation 
1700 Main Street 
Santa Monica. CA 90407 



HCFA Project Grace L. Lu-Yao, Ph.D. 
Officer: Division of Health Information 

and Outcomes 

Description: The purpose of this contract is to develop a 
monitoring system to assess access to care, quality of care, 
cost as well as patient satisfaction, and outcomes for 
Medicare and Medicaid programs. The investigators will 
review existing studies and data sources and propose a 
conceptual framework for a comprehensive monitoring 
and evaluation system, for Health Care Financing 
Administration (HCFA) programs. In addition, this 
project will identify indicators for each of the major 
domains in the conceptual framework and evaluate the 
validity and strengths of each proposed indicator. 
Furthermore, this project will advise HCFA on options for 
dissemination of information from the monitoring and 
evaluation system. 

Status: A draft for the Medicare monitoring system is 
under review. Work related to the Medicaid monitoring 
system is expected to be complete in July 1997. 

94-075 Development of a Global Quality 
Assessment Tool for Managed Care 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-90315/9 
September 1994— January 
$ 1,579,386 
Cooperative Agreement 



1998 



Elizabeth McGlynn, Ph.D. 
Rand Corporation 
1700 Main Street 
P.O. Box 2138 

Santa Monica, CA 90407-2138 
M. Beth Benedict, Dr. P.H. 
Division of Health Information 
and Outcomes 



Description: This project will develop and test a clinically 
based method for assessing the quality of care delivered 
for a broad range of services in managed-care health 
plans. It will focus on the quality of care delivered to 
children and to women under 45 years of age. 

Status: The project has identified the quality-of-care 
indicators, has conducted the panel meetings of experts, 
and is preparing to obtain the managed-care medical 
records to validate the new indicators. 

93-033 Drug-Utilization-Review Evaluation Contract 



Project No.: 
Period: 
Funding: 
Award: 



500-93-0002 
March 1 993-February 
$ 4,604,856 
Contract 



998 



Theme I : Monitoring and Evaluating Health System Performance 



Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



David Kidder, Ph.D. 
Abt Associates, Inc. 
55 Wheeler Street 
Cambridge, MA 02138 
Kathleen Gondek, Ph.D. 
Division of Payment Systems 

Omnibus Budget Reconciliation Act 
of 1990 (Public Law 101-508) 



Description: The purpose of this evaluation is to provide 
generalizable findings on the impacts of retrospective and 
prospective drug utilization review. Data from the two 
demonstration States (Iowa and Washington) and 
information on Medicaid drug-utilization-review activities 
from other States will form the basis of the evaluation 
findings. Georgia and Maryland will serve as co- 
experimental and comparison States. To test the effects of 
online, prospective, drug-utilization review and of paying 
pharmacists for cognitive services on drug problems, drug 
use and costs, other health services' use and costs, and 
access to services will be measured. In addition, surveys to 
pharmacists and physicians will be conducted to assess 
changes in the behavior related to the demonstration's 
interventions. 

Status: The final evaluation plan and preliminary analysis 
of the pre-demonstration period have been completed. 
Analysis of the Washington demonstration project is due 
June 1997. The final report is due March 1998. 

94-118 Estimating Mammography Utilization by 
Elderly Medicare Women for Whom the Health 
Care Financing Administration Does Not Receive 
Administrative Claims 

Project No.: 500-92-0020DO1 1 

Period: September 1994— September 1996 

Funding: $ 110,074 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Janet B. Mitchell, Ph.D. 

Awardee: Health Economics Research, Inc. 

(See page 193) 
HCFA Project Anne E. Trontell, M.D. 
Officer: Division of Health Information 

and Outcomes 

Description: This delivery order will provide basic 
information relevant to the use of the Health Care 
Financing Administration's (HCFA) administrative 
claims data for monitoring the use of preventive services 
in HCFA's Consumer Information Initiative, information 
developed under this delivery order will assist in 
understanding potential deficiencies in HCFA's 
administrative claims data for measuring mammography 



utilization, since self-reported utilization of 
mammography is typically higher than rates calculated 
from Part B claims data. The project will identify 
potential reasons for discrepancies between survey and 
claims data and will attempt to quantify the magnitude of 
discrepancies. Preliminary analyses suggest a role for 
person-level comparison of the survey reports and claims 
experience of Medicare Current Beneficiary Survey 
(MCBS) respondents. 

HCFA intends to monitor the use of mammography by its 
elderly female beneficiaries and so wishes to understand 
the strengths and weaknesses of administrative data for 
this monitoring function. Understanding the differences 
between claims-based rates and those based on survey 
self-reports will facilitate joint mammography efforts with 
the Public Health Service (PHS). These include the 
mammography screening objectives of the PHS Healthy 
People 2000 and the health services research goals of the 
Secretary's National Breast Cancer Action Plan. 

Status: The final report is in under review. 

94-017 Evaluating Methods of 
Estimating Hospital Efficiency 

Project No.: 500-93-0029DO02 

Period: December 1993-September 1995 

Funding: $ 296,575 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Robert J. Schmitz, Ph.D. 

Awardee: Abt Associates, Inc. 

55 Wheeler Street 
Cambridge, MA 02138-1168 

HCFA Project William L. England, Ph.D., J.D. 

Officer: Division of Health Information 

and Outcomes 

Description: This project used data envelopment analysis 
(DEA) using IDEAS software, and stochastic frontier 
analysis (SFA) using LIMDEP, Version 6 software, to 
assess the process by which hospitals provide patient care 
"output" as a function of input prices, in an effort to 
measure the elusive concept of hospital efficiency and 
quality of care. These methods assume that "similar" 
hospitals should produce equivalent patient care at similar 
costs and the extent to which they differ is a measure of 
inefficiency. The definition of "similar" is critical to the 
analysis, and Phase I of this project reviewed the literature 
on DEA and SFA to determine what variables (e.g., size, 
case mix, teaching status, local wage level) should be used 
to adjust for differences among hospitals. 

In Phase II of the project, a computer simulation model 
was developed to generate data from a known model of 
hospital cost and efficiency. This model was used to 



Theme 1 : Monitoring and Evaluating Health System Performance 



assess the ability of DEA and SFA to estimate the true 
efficient frontier, and to measure the cost of inefficiency, 
by "endowing" the model with given degrees of 
inefficiency. The model was also used to assess the 
validity and robustness of DEA and SFA to random noise, 
measurement error, and missing data. Data for the model 
include institution-specific employment data from the 
American Hospital Association; data from the Health 
Care Financing Administration's (HCFA) Hospital Cost 
Report Information System; U. S. Bureau of the Census 
data: State-specific files, including data from the 
California Office of Statewide Health Planning and 
Development and the Pennsylvania Medical database; and 
data on individual stays for Medicare beneficiaries from 
HCFA's Medicare provider analysis and review database. 

Status: This project is completed, and the final report is 
currently under review. 

93-031 Evaluation of Medicare SELECT 

Project No.: 500-93-0001 

Period: February 1993— December 1996 

Funding: S 1,275,091 

Award: Contract 

Principal 

Investigator: Steven Garfinkel, Ph.D. 

Awardee: Research Triangle Institute 

P.O. Box 12194 

Research Triangle Park, NC 27709-2194 
HCFA Project Sherry A. Terrell, Ph.D. 
Officer: Division of Delivery Systems 

and Financing 

Mandate: Section 4358(d) of the Omnibus 

Budget Reconciliation Act of 1990 
(Public Law 101-508 and 
Public Law 104-18) 

Description: Medicare SELECT is an experimental 
Medicare supplemental insurance product under which 
full Medigap benefits are paid only when services are 
provided by the plan's provider network. This evaluation 
was limited to the January 1992 through December 1994 
period and consisted of two components. First, case 
studies of each of the 15 States — Alabama, Arizona, 
California, Florida, Illinois. Indiana, Kentucky, 
Massachusetts. Minnesota, Missouri, North Dakota, Ohio, 
Texas. Washington, and Wisconsin — which were 
permitted to operate Medicare SELECT plans during the 
demonstration period, described all aspects of the 
development and operational processes used by the State 
Insurance Commissioners, the National Association of 
Insurance Commissioners, and insurers to implement the 
Medicare SELECT provisions. Second, an analytical 
component compared various measures associated with 
icarc M.I E< I to standard Medigap insurance 



options. Measures included cost and use of Medicare and 
supplemental services, selection effects, and beneficiary 
satisfaction. When Public Law 104-18 extended the 
demonstration for 3 years and expanded it to all 50 States, 
SELECT activity was updated through June 1996. 

Status: This project has been completed. Findings were 
based on the case studies, a beneficiary survey, an insurer 
survey and claims analyses. The beneficiary survey was 
conducted in 6 of the 1 5 States — Alabama, Arizona, 
Florida, Missouri, Texas and Wisconsin — to determine 
satisfaction, access to services, and quality of care 
received. Compared to the nationwide population of 
Medicare beneficiaries with standard Medigap policies, 
SELECT enrollees were younger and more likely to be 
male, Black, or Hispanic and to report lower incomes and 
education. There was no difference in SELECT and 
comparison-group enrollees on four measures of self- 
reported health status. The cost of the premium was the 
most important factor in enrollees' choice of SELECT 
policies. In every State, SELECT enrollees were satisfied 
or very satisfied with their Medicare supplemental plan. 
Impact evaluation findings produced more mixed results. 
Access to services and satisfaction with policies was the 
same for both Medicare SELECT and traditional Medigap 
policyholders. In regard to the cost to the Medicare 
program, the original premise of SELECT was that it 
would reduce aggregate health care costs because 
SELECT insurers would have an incentive to establish 
health cost-effective provider networks. And on the basis 
of the case study, it was expected that there would be little 
or no effect of SELECT on utilization or costs. However, 
in the first 3 years of the SELECT demonstration, 
Medicare program costs increased in five participating 
States, decreased in four States and were not affected in 
two States. Cost increases were generally associated with 
Part B utilization. A comparison of premiums 
standardized on age, gender, and risk factors indicated 
that in 1994 and 1995, where the same standardized plan 
is offered by the same insurer, SELECT premiums for a 
65-year-old are almost always lower in price. However, by 
age 75, SELECT premiums exceed those of the 
comparison community-rated plan, likely reflecting the 
practice by some SELECT plans of selling age-attained 
policies. The following reports are available from the 
National Technical Information Service: 

• "Evaluation of the Medicare SELECT Amendments: 
Case Study Report," accession number PB95-201489. 

• "Evaluation of the Medicare SELECT Amendments: 
Final Evaluation Report, December 1995 as revised 
February 1996," accession number PB96-157417. 

In addition, the investigators presented, "The Impact of 
Medicare SELECT on Cost and Utilization," at the 13th 
Annual Meeting of the Association of Health Service 
Research, Atlanta, June 9-11, 1996. 



"heme 1: Monitoring and Evaluating Health System Performance 



96-076 Evaluation of the District of Columbia's 
Demonstration Project: Managed-Care System for 
Disabled and Special Needs Children 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0003 

September 1996-March 2000 

S 1,203,963 

Contract 

Carol Irvin, Ph.D. 
Abt Associates, Inc. 
55 Wheeler Street 
Cambridge, MA 02138-1168 
Phyllis A. Nagy, MHS 
Division of Aging and Disability 



Description: The District of Columbia submitted a waiver- 
only request for Medicaid waivers under section 
1 1 15(a)(1) for a 3-year demonstration project to test the 
efficacy of a managed-care service-delivery system 
designed for children and adolescents under the age of 
22 who are eligible for Medicaid and are considered 
disabled according to Supplementary Security Income 
(SSI) Program guidelines. This study represents a unique 
opportunity to examine the experiences of a managed-care 
system with voluntary enrollment of children with 
disabilities. The project, which seeks to integrate acute 
and long-term-care services for children with disabilities 
into a single-capitated payment methodology, is the first 
approved demonstration of its kind. The information 
gathered will be used to inform both State and Federal 
policymakers who have increasingly come to regard 
managed care as a mechanism to contain growing health 
care expenditures. 

This study will provide for a special analysis of the 
enrollment and disenrollment processes, as well as of the 
project's implementation process (including enrollment 
and participation, services/benefits, provider participation 
and training, organizational and administrative issues, 
contracting and risk-sharing arrangements, provider fee 
schedules, community involvement, and quality 
assurance, administrative and data management systems). 
Outcome analyses will focus on enrollee/family outcomes 
(including care management, service utilization and costs, 
enrollee/family satisfaction, quality-of-care and health 
status indicators, access to care, and family/informal care 
giving), organizational outcomes (including an analysis of 
HSCSN's financial performance, and the risk-sharing 
arrangements between HSCSN and the District of 
Columbia), and the impact upon the provider community. 
Data for the evaluation will come from surveys (primary 
data collection), case study interviews, focus groups, 
Medicaid Management Information System and encounter 
data, and SSI data. 



Status: The project was awarded in September 1996, and 
is in the early stages of development and implementation. 

95-003 Evaluation of the Effectiveness of the 
Operation Restore Trust Demonstration 

Project No.: 500-92-0014DO06 

Period: September 1995-September 1997 

Funding: $ 738,062 

Award: Contract 

Principal 

Investigator: Robert Coulam, Ph.D., J.D. 

Awardee: Abt Associates, Inc. 

(See page 64) 

HCFA Project Edward Norwood 

Officer: Division of Demonstrations Support 

Description: The purpose of this contract is to conduct an 
evaluation of the demonstration project, Operation 
Restore Trust. The Office of Inspector General (OIG), the 
Administration on Aging (AOA), and the Health Care 
Financing Administration have jointly developed a model 
to demonstrate improved methods for investigation and 
prosecution of fraud and abuse in the provision of care or 
services under the health programs established by the 
Social Security Act, Public Law 90-248, section 402 
(a)(l)(J). The effort will consolidate the talents and 
expertise of the staff of the partner and other Federal 
agencies in five designated States and will focus on home 
health agencies, hospices, nursing facilities, and durable 
medical providers. 

The evaluation will determine whether the more 
concentrated effort rendered through the partnership 
model is effective and what impact the partnership model 
has on industry fraudulent behavior. The demonstration is 
scheduled to be conducted for a 2-year period ending 
February 27, 1997. 

Status: This project is in the developmental stage. An 
interim report was received November 1996. The final 
report is expected in late 1997. 

91-078 Evaluation of the Essential Access Community 
Hospital/Rural Primary Care Hospital Program 



Project No.: 
Period: 
Funding: 
Award: 



Investigator: 
Awardee: 



500-87-0028TO16 

September 1991-March 1995 

$ 718,109 

Technical Support: 

Evaluation of Demonstrations 

Principal 

George E. Wright, Ph.D. 

Mathematica Policy Research, Inc. 

P. O. Box 2393 

Princeton, NJ 08543-2393 



Theme 1 : Monitoring and Evaluating Health System Performance 



11 



HCFA Project 

Officer: 



Mandate: 



Sheldon Weisgrau 

Division of Delivery Systems 

and Financing 

Section 1820 of the Social Security Act 
(Public Law 101-239) 



Description: The Essential Access Community Hospital/ 
Rural Primary Care Hospital (EACH/RPCH) program is 
designed to assist States in maintaining access to health 
care services in rural areas through the development of 
rural health plans, establishment of rural health networks, 
and creation of a limited-service alternative for 
communities that can no longer support a full-service 
hospital. The EACH'RPCH program consists of: 

• A permanent operating program that establishes the 
EACH as a new hospital category and the RPCH as a 
new type of health care facility that provides 
emergency, outpatient, and limited inpatient services. 

• Grants to States and hospitals to assist in the 
development and implementation of the program. 

EACHs, RPCHs, and other health care providers are 
organized into rural health networks that maintain 
agreements for such services as the transfer and referral of 
patients, the provision of transportation services, and the 
development and use of communications systems. Seven 
States — California, Colorado, Kansas, New York, North 
Carolina, South Dakota, and West Virginia — participate 
in the program. 

The Health Care Financing Administration contracted 
with Mathematica Policy Research (MPR) to conduct an 
evaluation of the development, implementation, and early 
operating experience of the EACH/RPCH program. This 
project also includes an analysis of the Montana Medical 
Assistance Facility Demonstration, a forerunner of the 
EACH/RPCH program. 

Status: A final report on this project was completed in 
1996. Evaluation findings indicate that limited-service 
hospital models occupy a niche in rural health care 
systems — they fill a needed role by offering some 
hospitals an alternative to closure, but there are also 
limitations to participation. The financial benefits of 
participation in a limited-service hospital program vary by 
facility, depending on such factors as cost structure, 
provider supply, and service-use patterns in the 
community. The study indicates that program flexibility is 
needed to address local issues and that linkage of primary 
care services to developing networks is essential. The 
evaluators caution, however, that these findings are based 
on limited data and that additional program operating 
experience is necessary to draw firm conclusions on the 
impact of the program. 



95-015 Evaluation of the Iowa Implementation 
of Ambulatory Patient Groups (APGs) 

Project No.: 500-92-0047D002 

Period: April 1995-July 1997 

Award: Delivery Order in Master Contract 

Funding: $ 322,218 

Principal 

Investigator: Suzanne Felt-Lisk 

Awardee: Mathematica Policy Research, Inc. 

(Seepage 138) 

HCFA Project Joseph M. Cramer 

Officer: Division of Payment Systems 

Description: Under this contract, Mathematica will design 
and implement an evaluation of the Iowa Medicaid 
Program outpatient prospective payment system. Iowa will 
use the ambulatory patient group (APG) system developed 
by 3M-Health Information Systems. The focus of the task 
will be to perform a preliminary evaluation of the APG 
system using data collected from the facilities and the 
State. In addition, Mathematica will describe the 
implementation of APGs in two Blue Cross/Blue Shield 
plans in California and Ohio. The evaluation activities to 
be conducted by the contractor will consist of a case study 
of Iowa's development and implementation of the APG 
system followed by an analysis of the project's reimburse- 
ment methodology. The purpose of the analysis is to 
assess the application of the APG system for potential 
implementation by Medicare on a national basis. 

Status: The contract is being modified to place more 
emphasis on payers using APGs as a payment mechanism 
for ambulatory surgical centers and less emphasis on data 
analysis. An interim report on the implementation of 
APGs is being prepared and is expected to be completed 
in November 1996. 

96-061 Expansion of the Medicare 
Current Beneficiary Survey 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-94-0016 

September 1 996-December 1997 

$ 500,012 

Contract 

Brad Edwards 
Westat Corporation 
1650 Research Boulevard 
Rockville, MD 20850 
Franklin Eppig 
Office of the Actuary 



Description: The Medicare Current Beneficiary Survey 
(MCBS) is a longitudinal, multipurpose survey of a 
representative sample of the Medicare population, with 
over sampling of the disabled and the very old. Both 



heme I : Monitoring and Evaluating Health System Performance 



institutionalized persons and those residing in the 
community are included. Respondents are asked about 
service utilization, out-of-pocket expenses, health status, 
access to and satisfaction with care, and supplementary 
health insurance. Currently, about 16,000 Medicare 
beneficiaries are interviewed each Fall, about 1,000 of 
whom are in risk-based health maintenance 
organizations. 

Because of the continued growth of Medicare risk 
contracting, and the important policy issues involved, the 
MCBS is being expanded to incorporate more of a 
managed-care focus. There are three facets to the 
expansion: 

• The addition of 1 ,900 community sample members on a 
cross-sectional (one-time) basis to increase the 
representation of managed-care enrollees. 

• Addition of a limited number of questions which relate 
to managed-care issues. 

• Developmental work to improve the accuracy of service 
utilization reporting on the part of HMO enrollees. 

Status: The 1,900 additional sample members were 
interviewed in the Fall 1996. The additional survey 
questions on managed care were included in the Fall 1996 
round. Developmental work on utilization reporting has 
begun. 

95-070 Exploratory Study of the Effects of 
Managed Care on Urban Hospitals: ANASYS 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-95-0024 

July 1995-March 1996 

$ 80,000 

Contract 

Joshua S. Park 

ANASYS 

10805 Hickory Ridge Road, Suite 200-B 

Columbia, MD 21044 

Jay Bae, Ph.D. 

Division of Payment Systems 



Description: The growth of managed-care organizations is 
rapidly changing the way hospitals conduct business in 
many parts of the country. Where the managed-care 
sector's presence is felt significantly, the hospitals must 
compete for contracts with these managed-care plans. 
Increasing shares of managed-care contracts, however, 
can affect the behavior of hospitals considerably. The 
purpose of this project is to develop alternative measures 
of managed care's impact by metropolitan statistical 
(MSAs), areas and explore the possibilities of using such 
measures in analyzing the impact of managed-care on 
urban hospitals. 

Status: As an exploratory attempt to test and identify 



suitable measures of managed care's financial impacts on 
urban hospitals, this project created financial data files for 
urban short-term hospitals using the Medicare Hospital 
Cost Report Information System (HCRIS) between 1986 
and 1994. Regression analyses are conducted to consider a 
number of managed-care impact variables such as level 
and rate of changes in the health maintenance 
organization (HMO) penetration, MSA level Herfmdahl 
index for inpatient hospital services and HMO 
competition index. Additionally, a number of HMO 
inpatient utilization measures such as numbers of 
admissions and inpatient days at the MSA level were 
constructed from the HCRIS and employed for analyses. 
Descriptive statistics of Medicare hospitalizations are 
provided among high and low managed-care impact 
areas. This project was completed, and a final report was 
received in March 1996. 

94-105 Extension of Medicaid Benefits 
for Post-Partum Women 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00007/4 

January 1 994-December 1998 

Waiver-only Project 

Gwen Power 

South Carolina Department of 
Health and Human Services 
P. O. Box 8206 
Columbia, SC 29202-8206 
Suzanne Rotwein, Ph.D. 
Division of Health Information 
and Outcomes 



Description: South Carolina's Extension of Medicaid 
Benefits for Post-Partum Women seeks to increase the 
amount of time between pregnancies by extending and 
expanding family planning services to post-partum 
women. Under current law, if a woman is eligible for 
Medicaid only because of her pregnancy (i.e., her income 
is otherwise too high), Medicaid family planning benefits 
continue for 60 days after giving birth. In this project, 
South Carolina is extending coverage for an additional 
22 months. The project is expected to serve approximately 
20,000 women a year. Women whose family income is at 
or below 185 percent of the Federal poverty level at the 
time of giving birth are eligible for a defined set of family 
planning services during the additional 22-month period, 
without regard to subsequent changes in income level. 
South Carolina will evaluate the project by using State 
vital records and Medicaid Management Information 
Systems data to do trend analyses within comparable 
populations to measure the effect of the demonstration. 
Measures will include pregnancies averted or postponed 
and improvement in birth outcomes (e.g., reductions in 
premature births, low birth weight, neonatal intensive 
care unit cases). 



Theme 1 : Monitoring and Evaluating Health System Performance 



13 



Status: The project became operational on July 1, 1994. 
An amendment has been submitted to Health Care 
Financing Administration to expand the demonstration to 
include all women of childbearing age with incomes up to 
185 percent of the Federal poverty level, without regard to 
pregnancy status. Rather than limiting family planning 
services to 22 additional months post-partum, all women 
would be offered family planning services for the duration 
of the project. 

90-01 1 Home Care Quality Studies 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 

Officer: 



500-89-0056 

October 1 989-September 1995 

S 2,848,782 
Contract 

Robert L. Kane, M.D. 

University of Minnesota 

School of Public Health 

D-351 Mayo Memorial Building 

420 DeLaware Street, SE., Box 197 

Minneapolis, MN 55455-0392 

Phyllis A. Nagy 

Division of Aging and Disability 



Description: This study examines quality of long-term- 
care services in community-based and custodial settings, 
and the effectiveness of (and need for) State and Federal 
protections for Medicare beneficiaries that ensure 
adequate access to nonresidential long-term-care services 
and protection of consumer rights. The research design 
focuses on in-home care, examining traditional home 
health services that are reimbursed by Medicare and 
Medicaid, as well as personal care and supportive services 
that more recently have been covered by Federal and State 
sources of funding. Primary project tasks include: 

• Development of a taxonomy clarifying the various 
objectives ascribed to home and community-based care 
from the various perspectives of consumers, payers, and 
care providers. 

• Development and feasibility testing of a survey design 
measuring the extent of, need for, and adequacy of 
home care services for the elderly. 

• A study of variations in labor supply and related 
effect(s) on home care quality, as well as factors that 
contribute to these variations. 

• Recommendations to improve the quality of home and 
community-based services by identifying best practices 
and promising quality assurance approaches. 

Status: The first project task — development of a taxonomy 
of objectives — has been completed, and a report on this 
component has been received. Findings from this task are 
presented in the article, "Perspectives on Quality of Home 
Tare" by Kane. R. A., Kane, R. L., Illston, L. H., and 



Eustis, N. N. in the Health Care Financing Review, 
Volume 16, Number 1, pp. 69-89, Fall 1994. Final reports 
have also been submitted on the remaining three project 
tasks (i.e., developing a survey to measure the adequacy of 
home care for the elderly, a study of variations in labor 
supply and related effects on home care quality, and an 
identification of best home care practices and promising 
quality assurance approaches). The final report for the 
project is currently under review. 

94-039 Hospital Obstetrical Care: A Comparison of 
Quality Indicators in Medicaid Fee-for-Service and 
Medicaid Managed-Care Groups 

Project No.: 18-P-90429/5 

Period: September 1 994-November 1996 

Funding: $257,681 

Award: Grant 

Principal 

Investigator: Denise M. Oleske, Ph.D. 

Awardee: Rush University 

1653 West Congress Parkway 

Chicago, IL 60612-3833 
HCFA Project Judith A. Sangl, Sc.D. 
Officer: Division of Health Information 

and Outcomes 

Description: The objectives of this study are to describe 
and ascertain differences in the prevalence of clinical 
quality indicators in Medicaid fee-for-service, Medicaid 
managed care, and private managed-care groups for 
maternal and child hospital obstetrical care. Data from 
California and Florida will be used. Data sources for this 
project include birth and fetal death certificates, hospital 
discharge abstracts, Medicaid eligibility files, and the 
American Hospital Association Annual Survey. 

Status: A draft report is under review. 

94-109 Identifying Drug Therapy Inappropriateness: 
Determining the Validity of Drug Use Review 
Screening Criteria 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



18-C-90302/3 
September 1994— January 
$ 209,428 
Cooperative Agreement 



1997 



HCFA Project 
Officer: 



Ilene Zuckerman, Pharm.D. 
University of Maryland at Baltimore 
Center on Drugs and Public Policy 
School of Pharmacy 
5 1 1 West Lombard Street 
Baltimore, MD 21201 
Kathleen Gondek, Ph.D. 
Division of Payment Systems 



14 



Theme 1: Monitoring and Evaluating Health System Performance 



Description: The purpose of this study is to determine if 
outpatient drug-use-review (DUR) screening identifies 
clinically significant cases of inappropriate drug 
prescribing in the Medicaid program. The objectives of 
the study are: 

• Quantify the agreement between a DUR screening of 
Maryland Medicaid claims data and the medical record. 

• Test the hypothesis that cases of appropriate 
antihypertensive drug therapy are associated with lower 
mean blood pressures. 

• Outline a method to establish standards of acceptable 
variation from the drug therapy inappropriateness 
criteria for drugs used to treat hypertension. 

• Produce a manual for Medicaid DUR programs on 
assembling a minimal data set to permit an ongoing 
assessment of the usefulness of DUR screening of 
Medicaid claims data. 

Status: Replication of the content validity of the screening 
criteria used to indicate drug therapy inappropriateness in 
the treatment of hypertension is complete. Practitioners 
have been trained to review medical records data and 
assess the drug therapy appropriateness. Completion of 
this project is anticipated in early 1997. 

92-031 Impact of the Medicare Fee Schedule 
on Access to Physician Services 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



17-C-90037/1 
March 1 992-September 
$ 768,498 
Cooperative Agreement 



996 



Janet B. Mitchell, Ph.D. 
Center for Health Economics 
Research, Inc. 
300 Fifth Avenue, 6th Floor 
Waltham, MA 02154 
Renee Mentnech 
Division of Delivery Systems 
and Financing 



Description: The purpose of this project is to evaluate the 
impact of the Medicare fee schedule (MFS) on access to 
care. A sample of beneficiaries will be selected for study 
from six strata reflecting the size of the payment change 
under the MFS. Access for vulnerable segments of the 
population will be measured both in terms of use and 
outcomes, as well as financial liability. National trend 
data also will be developed. In addition, changes in 
regular source of care and difficulties obtaining care will 
be assessed using the Medicare Current Beneficiary 
Survey (MCBS). 

Status: A nationally representative sample has been 
drawn, and Medicare use data have been assembled for 



the sample. Measures of outcomes (such as admissions for 
ambulatory care sensitive conditions) and use (such as use 
of preventive services) have been developed for vulnerable 
groups and for geographic areas by expected MFS 
payment change. The 1991 outcome and use measures 
were compared with the 1992 and 1993 data to identify 
any changes in the first and second years of the MFS. 
Access measures from rounds 1, 4, and 7 of the MCBS 
(1991, 1992, and 1993 data, respectively) have been 
developed. Results from this project have been 
incorporated into the 1993, 1994, and 1995 Reports to 
Congress on access. Substantial differences between 
vulnerable population subgroups were identified. 
Preliminary results suggest, however, that access neither 
worsened nor improved during the first and second years 
of MFS implementation. Data on private-sector fees have 
been incorporated into the model to determine whether 
providers substitute private-sector patients for Medicare 
patients in those areas with higher private-sector fees 
relative to Medicare. A final report is being drafted. 

94-090 Improving Measurement of Hospital Output 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



17-C-90447/9 

September 1 994-September 1996 

$ 285,924 

Cooperative Agreement 

Grace M. Carter, Ph.D. 

Rand Corporation 

1700 Main Street 

P.O. Box 2138 

Santa Monica, CA 90407-2138 

Philip G. Cotterill, Ph.D. 

Division of Payment Systems 



Description: The purpose of this project is to explore the 
policy implications of an improved way of measuring 
hospital output by combining the diagnosis-related-group 
(DRG) system for classifying discharges with the 
California standard-measurement-unit system for 
measuring the intensity of care per case-mix constant 
discharge. The project will estimate the annual change in 
California hospital output and compare this estimate with 
the method currently used by the Health Care Financing 
Administration. In addition, the project will analyze the 
extent to which case-mix constant intensity determines 
differences in cost among hospital groups. Since measures 
of hospital output are critical for the prospective payment 
system, the results of this project will help to validate 
current policies including the annual update and other 
adjustment factors. 

Status: The project has been extended until September 
1996 to permit completion of analyses of DRG weights 
and pricing strategies. A final report is expected by the 
end of 1996. 



Theme 1 : Monitoring and Evaluating Health System Performance 



15 



95-056 International Comparative Data and Analysis 
of Health Care Financing and Delivery Systems 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-95-0001 

August 1995-August 2000 

S 1,455,100 

Contract 

Jean Pierre Poullier 

Organization for Economic Cooperation 

and Development (OECD) 

2 Rue Andre Pascal 

75775 Paris Cedex 16 France 

Leslie M. Greenwald, Ph.D. 

Division of Delivery Systems 

and Financing 



Description: The Organization for Economic Cooperation 
and Development (OECD) has developed a unique data- 
base that contains information on health care financing 
and use in industrialized Western nations. The OECD 
will collect data on the following member countries: 
Australia, Austria, Belgium, Canada, Denmark, Finland, 
France, Germany, Greece, Iceland, Ireland, Italy, Japan, 
Luxembourg, the Netherlands, New Zealand, Norway, 
Portugal, Spain, Sweden, Switzerland, Turkey, the United 
Kingdom, and the United States. This project obtains 
these data on an ongoing basis and updates and expands 
them, along with a series of papers analyzing the trends 
in Western developed nations and their policy relevance 
to the United States. The importance of these data, in 
particular, is that they are the only country-to-country 
comparable figures (in terms of general definitions of 
health spending and methodology of their collection) of 
this type. 

Variables included in the annual database include 
individual country comparisons of: total health care 
expenditures; expenditures on various parts of health care 
spending, such as hospital or physician services; health 
outcomes measures, such as infant mortality rates and life 
expectancy; and country-specific economic indicators and 
demographic data. Together, these data are the source of 
statistics comparing health spending (usually expressed as 
a percentage of gross domestic product, or in U. S. dollars 
per capita) in the United States and other Western 
developed nations. In general, these data have for a 
number of years shown that U. S. spending, even when 
controlling for population and total gross domestic 
product, is far above that of other developed nations. 

Status: The contract was awarded in August 1995 and is 
in its second year. 



94-045 Interrelationship of Medical Conditions 
in the Nursing Home Population 

Project No.: 500-89-0047/43 

Period: January 1994-December 1995 

Funding: $ 67,600 

Award: Contract 

Principal 

Investigator: David Kennell 

Awardee: Lewin/VHI, Inc. 

(See page 17) 

HCFA Project Carolyn Rimes 

Officer: Division of Aging and Disability 

Description: This project, conducted in collaboration with 
the Health Care Financing Administration, uses 
concatenated Medicare provider analysis and review, 
skilled nursing facility (SNF), and minimum data set plus 
(MDS+) data to develop a richer profile of Medicare SNF 
patients. Data for all patients include their clinical 
conditions, their subsequent use of Medicare hospital and 
SNF services, and use of their non-Medicare-covered 
nursing home services. This is a pilot study that focuses 
on three States (Maine, Mississippi, and South Dakota) 
and on patients with selected conditions (congestive heart 
failure, hip fracture/replacement, chronic obstructive 
pulmonary disease, pneumonia, and cardiovascular 
attack). This study also examines the characteristics of 
nursing home patients who are under 65 years of age. 
This work has been subcontracted to the Urban Institute. 

Status: A draft paper has been received and reviewed. The 
project is expected to be completed in 
December 1996. 

94-102 Levels and Determinants 
of Hospital Inefficiency 

Project No. : 1 7-C-90285/4-0 1 

Period: September 1994-March 1996 

Award: Cooperative Agreement 

Funding: $ 146,042 

Principal 

Investigators: Thomas N. Chirikos, Ph.D., and 

Alan M. Sear, Ph.D. 
Awardee: University of South Florida 

4202 Fowler Avenue 

Tampa, FL 33620 
HCFA Project Edgar A. Peden, Ph.D. 
Officer: Division of Payment Systems 

Description: The principal objective of this project is to 
quantify current levels and historical rates of change in 
hospital inefficiency. To accomplish this goal, the 
investigators are using statistical analyses, including data 
envelopment analysis and frontier cost analysis. The 



Theme I : Monitoring and Evaluating Health System Performance 



database used included longitudinal information for 
hospitals in the State of Florida. As part of this analysis, 
the project identified the determinants of the level and 
changes in inefficiency, both within hospitals (e.g., 
organizational characteristics, arrangements with the 
medical staff, practice patterns) and those in the external 
environment to hospitals (e.g.. the degree of competition 
in the local health care market, regulations, technological 
diffusion). Finally, the project final report presents and 
discusses a number of policy recommendations based on 
the empirical findings that emphasize how hospital 
management practices andor external market 
characteristics might be shaped by Federal policymakers 
to further reduce hospital inflation. The investigators note 
that inefficiencies are on the general order of 14 percent 
of the best practice efficiency level, which indicates that 
hospital cost-containment efforts still have much to 
accomplish. 

Status: The investigators completed their analyses. 

92-027 Long-Term-Care Program and 
Market Characteristics 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-90034/9 

February 1 992-December 1995 

S 808,047 

Cooperative Agreement 

Charlene Harrington, Ph.D. 

University of California at 

San Francisco 

Office of Research Affairs 

3333 California Street, Suite 1 1 

San Francisco, CA 94143-0962 

Kay Lewandowski 

Division of Aging and Disability 



Description: This project will collect data on and study 
the effects of nursing home and home health care 
characteristics and markets on Medicare and Medicaid 
services in the 50 States. Primary and secondary data for 
the 1990-94 period will be collected to update earlier data 
on previous studies for the 1978-89 period. Through 
surveys, data will be collected on licensed nursing home 
bed supply and occupancy rates, State certificate of need 
programs, State pre-admission screening programs, and 
Medicaid nursing home and home health reimbursement. 
Data also are being collected on Medicaid waiver 
programs, Boren amendment litigation, provider 
characteristics, resident characteristics, and deficiencies 
of nursing homes. Analysis will provide detailed 
information on each State's current methodology for 
determining nursing home capital costs, the impact of 
proposed case-mix reimbursement on operating income, 
reimbursement methodology for freestanding subacute 
units, and Medicaid methodology used to reimburse for 



care provided in board and care homes, geriatric day care 
centers, and intermediate care facilities for the mentally 
retarded. A publicly accessible database will be developed 
that will provide a complete set of demonstration data for 
the period 1978-94. 

Status: This project has been completed. The second State 
databook presenting data on the long-term-care program 
and market characteristics across the 50 States and the 
District of Columbia has been published by the Health 
Care Financing Administration as State Data Book on 
Long-Term Care Program and Market Characteristics, 
1993, Health Care Financing Extramural Report, HCFA 
Publication Number 03366. U.S. Government Printing 
Office Washington, D.C. February 1995. The public use 
database and documentation have been received and are 
being reviewed. 

89-034 Long-Term-Care Studies (Section 207) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-89-0047 

September 1989-March 1996 

S 3,790,000 

Contract 

David Kennell 

Lewia'YHI, Inc. 

9302 Lee Highway, Suite 500 

Fairfax, VA 22031-1207 

Carolyn Rimes 

Division of Aging and Disability 



Description: The purpose of this project is to conduct 
research related to the Health Care Financing 
Administration's (HCFA's) Medicare and Medicaid 
programs in the area of long-term-care (LTC) policy 
development. The awardee has focused on four major 
areas: 

• The financial characteristics of Medicare beneficiaries 
who receive or need LTC services. 

• How the Medicare beneficiaries' characteristics affect 
their use of institutional and noninstitutional LTC 
services. 

• How relatives of Medicare beneficiaries are affected 
financially and in other ways when beneficiaries require 
or receive LTC services. 

• How the provision of LTC services may reduce 
expenditures for acute care health services. 

Analyses used existing LTC and other survey databases 
(e.g., the National Long-Term Care Surveys, the 
Longitudinal Study of Aging, the National Nursing Home 
Survey, the Medicare Current Beneficiary Survey, the 
Survey of Income and Program Participation, the National 
Medical Care Expenditure Survey). Medicare 
administrative records and other extant information also 
will be used. A number of focused analytic studies, policy 



Theme 1 : Monitoring and Evaluating Health System Performance 



17 



reports, syntheses, and special studies are required under 
the contract. 

Status: With the repeal of the Medicare Catastrophic 
Coverage Act of 1988, this project was no longer 
congressionallv mandated. The following updates the 
status of each of the studies, indicating which reports are 
final and those that are in draft or pending final review. 
The final reports are: 

• "Analysis of Choice Processes in Capitated Plan 
Enrollment: Statistical Models for Evaluation of 
Voluntary Enrollment to Long-Term-Care 
Demonstration Projects," 

• "Analysis of Transitions in the Characteristics of the 
Long-Term-Care Population" 
"Case Studies of Medicaid Estate Planning" 
"Consumer Protection and Private Long-Term-Care 
Insurance" 

"Elderly Wealth and Savings: Implications for Long- 
Term Care" 

"Health Care Service Use and Expenditures of the 
Noninstitutionalized Population" 
"Consumer Protection and Private Long-Term-Care 
Insurance: Key Issues for Private Long-Term-Care 
Insurance" 

"Issues in Long-Term Care for the Disabled Elderly 
with Cognitive Impairment" 
"Nursing Home Payment by Source: Preliminary 
Statistics from the Medicare Current 
Beneficiary Survey" 

"Potential of Coordinated Care Targeted to Medicare 
Beneficiaries with Medicaid Coverage" 
"Regional Variation in Home Health Episode Length 
and Number of Visits Per Episode" 
"Simulations of Skilled Nursing Facility Payment 
Options" 

"State Responses to Medicaid Estate Planning" 
"Synthesis of Financing and Delivery of Long-Term 
Care for the Disabled Non-Elderly" 
"Synthesis of Literature on Targeting to Reduce 
Hospital Use" 

"Synthesis of the Nursing Home Bed Supply" 
"Synthesis of Unmet Need for Long-Term-Care 
Services." 

A conference presenting selected findings was held in 
November 1994 and the conference proceedings, Persons 
with Disabilities: Issues in Health Care Financing and 
Senice Delivery, has been published. The proceedings is 
available from the Brookings Institute and HCFA's Office 
of Research and Demonstrations. Papers included in this 
book arc: 

• "Long-Term Care: The View from the Health Care 
Financing Administration" 

• "Private Long-Term-Care Insurance: Barriers to 
Purchase and Retention" 



"Medicaid Estate Planning: Case Studies of Four 

States" 

"Implications of Health Care Financing, Delivery and 

Benefit Design for Persons with Disabilities" 

"Program Payment and Utilization Trends for Medicare 

Beneficiaries with Disabilities" 

"Cognitive Impairment in Older People and Use of 

Physician Services and Impatient Care" 

"Catastrophic Costs of Long-Term Care for Elderly 

Americans" 

"Characteristics and Outcomes of Persons Screened in 

Connecticut's 2176 Program" 

"Combining Formal and Informal Care in Serving Frail 

Elderly Persons" 

"Regional Variation in the Use of Medicare Home 

Health Services" 

"Long-Term Care for the Younger Population: A Policy 

Synthesis." 

Studies currently in progress are: 

• "Catastrophic Health Care Expenditures and Medicaid 
Coverage Among Community Residents" 

• "Synthesis of Nursing Home Reimbursement Options" 

• "The Effect of Geographic Variation on Medicare 
Capitation Rates for the Social HMO, PACE, CNO" 

• "Synthesis of Literature on Effectiveness of Special 
Assistive Devices in Managing Functional 
Impairments" 

• "Catastrophic Costs and Medicaid Spenddown" 

• "Costs of Medicare SNF Therapy Services" 

• "Longitudinal Health Care Use and Expenditures of 
Disabled" 

• "Interrelationship of Medical Conditions in the Nursing 
Home Population" 

• "An Analysis of Post-Acute Care and Therapy Services 
Using the HCFA Episode Database, Post-Acute 
Portion." 



Final reports on these projects are expected to be 
completed in Spring 1997. 

94-087 Maximizing the Cost Effectiveness of 
Home Health Care: The Influence of Service 
Volume and Integration with Other Care Settings 
on Patient Outcomes 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



17-C-90435/8 

September 1 994-December 1998 

$ 1,231,466 

Cooperative Agreement 

Peter W. Shaughnessy, Ph.D. 
Center for Health Policy Research 
1355 South Colorado Blvd., Suite 706 
Denver, CO 80222 
Elizabeth Mauser, Ph.D. 
Division of Aging and Disability 



Theme 1: Monitoring and Evaluating Health System Performance 



Description: Home health care (HHC) is the most rapidly 
growing component of the Medicare budget in recent 
years. The rapid growth in home health use has occurred 
despite limited evidence about the necessary volume of 
HHC to achieve optimal patient outcomes and whether it 
substitutes for more costly institutional care. Little is 
known about integrating HHC with care in other settings 
to reduce overall health care costs. The central hypotheses 
of this study are that volume-outcome relationships are 
present in HHC for common patient conditions, that upper 
and lower volume thresholds exist that define the range of 
services most beneficial to patients, that and a 
strengthened physician role and better integration of HHC 
with other services during an episode of care can optimize 
patient outcomes while controlling costs. To test these 
hypotheses, a total of 3,600 patient records will be 
selected from agencies in 20 States. Trained data 
collectors at each agency will record patient health status 
and service information between HHC admission and 
discharge to assess patient outcomes and costs within the 
HHC episode. Long-term, self-reported outcomes will be 
assessed from telephone interview data at HHC admission 
and from 6-month follow-ups. These primary data 
concerning patient status and outcomes will be combined 
with Medicare claims data over the episode of care to 
assess the relationship between service volume in HHC 
and in both patient outcomes and costs. Analysis of data 
relating to physician involvement and the sequence of use 
of other providers will address issues of integration with 
other services. 

Status: Eighty-nine agencies have been recruited for this 
project and are beginning to collect the necessary data. 

95-023 Maximizing the Effective Use of Telemedicine: 
A Study of the Effects, Cost Effectiveness, and 
Utilization Patterns of Consultation via Telemedicine 

Project No.: 18-C-90617/8 

Period: September 1 995-September 1998 

Funding: $ 1,346,639 

Award: Cooperative Agreement 

Principal 

Investigators: Jim Grigsby, Ph.D., and 

Robert E. Schlenker, Ph.D. 
Awardee: Center for Health Policy Research 

University of Colorado 

Denver, CO 80202 
HCFA Project William L. England, Ph.D., J.D. 
Officer: Division of Health Information 

and Outcomes 

Description: The objective of this project is to design and 
conduct a comprehensive evaluation of the Health Care 
Financing Administration's (HCFA) telemedicine 
research demonstration projects. The awardee, in 
consultation with the individual demonstration sites, has 



formulated a cross-cutting evaluation design, including 
data collection and analysis, to assess the effect of 
alternative payment options for the providers of 
telemedicine services, including fee-for-service and a 
"bundled payment" approach. The awardee will devise 
objective measures of the cost of telemedicine services in 
different clinical settings, both from the payer's and the 
provider's perspective; will examine provider and patient 
satisfaction; will examine utilization measures such as 
physician visits, hospitalizations, complications or 
comorbidities, and the effect of telemedicine on practice 
patterns. HCFA expects to use information gained from 
this project to develop a cost-effective payment strategy 
for telemedicine services in Medicare. 

Status: The evaluation design has been completed and the 
awardee is waiting for review of the data collection 
instruments by the Office of Management and Budget 
(OMB). Data collection will begin as soon as the OMB 
approval is obtained. 

92-086 Medicaid Demonstration and Evaluation 
Support Projects: Master Contract: Mathematica 
Policy Research, Inc. (Formerly, Medicaid 
Demonstration and Evaluation Support Projects: 
Master Contracts) 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-92-0037 

September 1992-August 1996 

Contract 

George E. Wright, Ph.D. 
Mathematica Policy Research, Inc. 
600 Maryland Avenue, SW., Suite 550 
Washington, DC 20024-2512 
Bonnie M. Edington 
Division of Health Information 
and Outcomes 



Description: This master contract provides for the design, 
development, conduct, and evaluation of Medicaid 
demonstration and evaluation support projects. The intent 
of these demonstration projects is to obtain information in 
a timely manner for program and policy consideration. 

Status: This master contract was awarded in September 
1992. This awardee was able to compete for individual 
delivery orders (DOs) for 36 months. The first DO 
(awarded concurrently with the base contract) is for 
general management, which includes submitting monthly 
reports, meeting with the Federal Government on request, 
and responding to requests for issue papers. The overall 
36-month funding amount of the first DO, 500-92- 
0037DO01, management delivery order, is $27,569. The 
master contract was given a no-cost extension through 
August 1996. 



Theme 1: Monitoring and Evaluating Health System Performance 



19 



The individual DO project awarded under the master 
contract is described in detail in the following section of 
this edition of Active Projects Report. 

Theme 3: Meeting the Needs of Vulnerable Populations 
• Federally Qualified Health Centers, 500-92-0037DO03. 

96-052 Medicaid Early, Periodic Screening, 
Diagnosis and Treatment: Task Order: 
Jing Xing Health and Safety, Inc. 

Project No. 500-96-0026-0001 

Period: September 1996-September 1997 

Funding: S 95,805 

Award: Task Order 

Principal 

Investigator: George Kowalczyk 

Awardee: Jing Xing Health and Safety, Inc. 

7008-K Little River Turnpike 

Annandale, VA 22003 
HCFA Project Alan W. Bradt 
Officer: Division of Data Systems Resources 

Description: The contractor will provide programming, 
analytical, and statistical application skills in support of 
research activities for the Office of Research and 
Demonstrations. This task order is to study the utilization 
and expenditure patterns of children who received early 
and periodic screening diagnosis and treatment, and to 
examine health outcomes of children with regard to use of 
EPSDT and follow-up services. 

Status: The task order contract was awarded in 
September 1996 concurrently with the base contract. The 
delivery date is September 29, 1997. The total value of 
this task is 595,805. The base contract is identifier 
96-003. Other tasks are identifiers 96-051, 96-053, 
and 96-054. 

96-054 Multistate and Longitudinal Cohorts of 
Medicaid Children: Patterns of Enrollment, 
Ltilization and Expenditures: Task Order: 
Jing Xing Health and Safety, Inc. 



Project No. 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



I K FA Project 
Officer: 



500-96-0026-0004 
September, 1996-September 
S 123,590 
Task Order 



997 



George Kowalczyk 

Jing Xing Health and Safety, Inc. 

7008-K Little River Turnpike 

Annandale, VA 22003 

Alan W. Bradt 

Division of Data Systems Resources 



Description: The contractor will provide programming, 
analytical, and statistical application skills in support of 



research activities for the Office of Research and 
Demonstrations. This task order will further the Health 
Care Financing Administration's understanding of the 
patterns of enrollment, utilization and expenditures 
among Medicaid children by using Statistical Medicaid 
Research Files for 1992. 

Status: The task order contract was awarded in September 
1996 concurrently with the base contract. The delivery 
date is September 29, 1997. The total value of this task is 
$123,590. The base contract is identifier 96-003. Other 
tasks are identifiers 96-051, 96-052, and 96-053. 

79-001 Municipal Health Services Program: 
Baltimore, Maryland (Formerly, Municipal Health 
Services Program) 

Project No.: 95-P-51000 

Period: August 1979-December 1997 

Funding: Waiver only 

Award: Service Agreement 

Principal 

Investigator: Bernadette G. Greene 

Awardee: City of Baltimore 

1 1 1 North Calvert Street 

Baltimore, MD 21202 
HCFA Project Spike Duzor 
Officer: Office of Research and 

Demonstrations Support 

Description: Development of the Municipal Health 
Services Program (MHSP) was a collaborative effort of 
four major cities, the U. S. Conference of Mayors, the 
American Medical Association, the Robert Wood Johnson 
Foundation (RWJF), and the Health Care Financing 
Administration (HCFA). It was initiated by RWJF 
through grants of S3 million awarded in June 1978 to 
each of these cities: Baltimore, Cincinnati, Milwaukee, 
and San Jose. HCFA joined the project by providing 
Medicare and Medicaid waivers to test the effects of 
increased use of municipal health centers by eliminating 
coinsurance and deductibles, expanding the range of 
covered services, and paying the cities the full cost of 
delivering services at the clinics. The intent of the waivers 
is to shift fragmented use from costly hospital emergency 
rooms and outpatient departments toward lower cost 
MHSP clinics that would provide beneficiaries with 
comprehensive primary and preventive health care. 

Status: MHSP waivers were scheduled to be terminated on 
December 31, 1984; however, HCFA agreed to extend the 
Medicare waivers through December 1985. With the 
passage of the Omnibus Budget Reconciliation Act 
(OBRA) of 1989, the demonstrations were extended to 
December 31, 1993. In addition, OBRA 1989 mandated 
that an independent evaluation regarding program cost- 
effectiveness, beneficiary costs, quality of care, and other 



20 



heme 1: Monitoring and Evaluating Health System Performance 



relevant factors be undertaken and that the findings of the 
evaluation be submitted in a report to Congress. HCFA 
contracted with Mathematica Policy Research, Inc. (MPR) 
to perform the independent evaluation. MPR reported that 
the MHSP program has grown since 1985 in terms of cost 
and use. The total of gross Medicare waiver services costs 
for the MHSP program from fiscal years 1985-92 was 
S225 million. A review of the MHSP cost reports 
indicated that a large proportion of the increase in 
program costs was caused by the rise in the use of high- 
cost ancillary services, such as prescription drugs, dental 
care, and vision care. OBRA 1993 again extended the 
demonstration through December 31, 1997. HCFA 
contracted with MPR to focus on the following three areas 
of inquiry which were not addressed in their 1993 study: 
impact to the Medicaid program, access to care, and 
utilization differences among different populations served 
by the demonstration sites. 

79-003 Municipal Health Services Program: 
Cincinnati. Ohio (Formerly, Municipal Health 
Services Proaram) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



95-P-51000 

August 1979-December 1997 

Waiver only 

Service Agreement 

Malcolm P. Adcock. Ph.D. 
City of Cincinnati 
3101 Burnet Avenue 
Cincinnati, OH 45229 
Spike Duzor 
Office of Research and 
Demonstrations Support 



Description: Development of the Municipal Health 
Services Program (MHSP) was a collaborative effort of 
four major cities, the U. S. Conference of Mayors, the 
American Medical Association, the Robert Wood Johnson 
Foundation (RWJF). and the Health Care Financing 
Administration (HCFA). It was initiated by RWJF 
through grants of S3 million awarded in June 1978. to 
each of these cities: Baltimore. Cincinnati. Milwaukee, 
and San Jose. HCFA joined the project by providing 
Medicare and Medicaid waivers to test the effects of 
increased use of municipal health centers by eliminating 
coinsurance and deductibles, expanding the range of 
covered services, and paying the cities the full cost of 
delivering services at the clinics. The intent of the waivers 
is to shift fragmented use from costly hospital emergency 
rooms and outpatient departments toward lower cost 
MHSP clinics that would provide beneficiaries with 
comprehensive primary and preventive health care. 

Status: MHSP waivers were scheduled to be terminated on 
December 31. 1984; however, HCFA agreed to extend the 



Medicare waivers through December 1985. With the 
passage of the Omnibus Budget Reconciliation Act 
(OBRA) of 1989, the demonstrations were extended to 
December 31, 1993. In addition, OBRA 1989 mandated 
that an independent evaluation regarding program cost 
effectiveness, beneficiary costs, quality of care, and other 
relevant factors be undertaken and that the findings of the 
evaluation be submitted in a report to Congress. HCFA 
contracted with Mathematica Policy Research, Inc. (MPR) 
to perform the independent evaluation. MPR reported that 
the MHSP program has grown since 1985 in terms of cost 
and use. The total gross of Medicare waiver services costs 
for the MHSP program from fiscal years 1985-92 was 
S225 million. A review of the MHSP cost reports 
indicated that a large proportion of the increase in 
program costs was caused by the rise in the use of high- 
cost ancillary services, such as prescription drugs, dental 
care, and vision care. OBRA 1993 again extended the 
demonstration through December 31, 1997. HCFA 
contracted with MPR to focus on the following three areas 
of inquiry which were not addressed in their 1993 study: 
impact to the Medicaid program, access to care, and 
utilization differences among different populations served 
by the demonstration sites. 

79-004 Municipal Health Services Program: 
Milwaukee, Wisconsin (Formerly, Municipal 
Health Services Program) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



95-P-51000 

August 1979-December 1997 

Waiver only 

Service Agreement 

Samuel Akpan. Ph.D. 
City of Milwaukee 
841 North Broadway 
Milwaukee, WI 53202 
Spike Duzor 
Office of Research and 
Demonstration Support 



Description: Development of the Municipal Health 
Services Program (MHSP) was a collaborative effort of 
four major cities, the U. S. Conference of Mayors, the 
American Medical Association, the Robert Wood Johnson 
Foundation (RWJF), and the Health Care Financing 
Administration (HCFA). It was initiated by RWJF 
through grants of S3 million awarded in June 1978, to 
each of these cities: Baltimore. Cincinnati, Milwaukee, 
and San Jose. HCFA joined the project by providing 
Medicare and Medicaid waivers to test the effects of 
increased use of municipal health centers by eliminating 
coinsurance and deductibles, expanding the range of 
covered services, and paying the cities the full cost of 
delivering services at the clinics. The intent of the waivers 
is to shift fragmented use from costly hospital emergency 



Theme 1 : Monitoring and Evaluating Health System Performance 



21 



rooms and outpatient departments toward lower cost 
MHSP clinics that would provide beneficiaries with 
comprehensive primary' and preventive health care. 

Status: MHSP waivers were scheduled to be terminated on 
December 31. 1984; however, HCFA agreed to extend the 
Medicare waivers through December 1985. With the 
passage of the Omnibus Budget Reconciliation Act 
(OBRA) of 1989, the demonstrations were extended to 
December 31, 1993. In addition, OBRA 1989 mandated 
that an independent evaluation regarding program cost- 
effectiveness, beneficiary costs, quality of care, and other 
relevant factors be undertaken and that the findings of the 
evaluation be submitted in a report to Congress. HCFA 
contracted with Mathematica Policy Research, Inc. (MPR) 
to perform the independent evaluation. MPR reported that 
the MHSP program has grown since 1985 in terms of cost 
and use. The total gross of Medicare waiver services costs 
for the MHSP program from fiscal years 1985-92 was 
$225 million. A review of the MHSP cost reports 
indicated that a large proportion of the increase in 
program costs was caused by the rise in the utilization of 
high-cost ancillary services, such as prescription drugs, 
dental care, and vision care. OBRA 1993 again extended 
the demonstration through December 31, 1997. HCFA 
contracted with MPR to focus on the following three areas 
of inquiry which were not addressed in their 1993 study: 
impact to the Medicaid program, access to care, and 
utilization differences among different populations served 
by the demonstration sites. 

79-002 Municipal Health Services Program: 
San Jose, California (Formerly, Municipal 
Health Services Program) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



95-P-51000 

August 1 979-December 1997 

Waiver only 

Service Agreement 

JoAnn Foreman 

City of San Jose 

151 West Mission Street 

San Jose, CA 951 10 

Spike Duzor 

Office of Research and 

Demonstrations Support 



Description: Development of the Municipal Health 
Services Program (MHSP) was a collaborative effort of 
four major cities, the U. S. Conference of Mayors, the 
American Medical Association, the Robert Wood Johnson 
Foundation (RWJF), and the Health Care Financing 
Administration (HCFA). It was initiated by RWJF 
through grants of $3 million awarded in June 1978, to 
each of these cities: Baltimore. Cincinnati, Milwaukee, 
and San lose HCFA joined the project by providing 



Medicare and Medicaid waivers to test the effects of 
increased use of municipal health centers by eliminating 
coinsurance and deductibles, expanding the range of 
covered services, and paying the cities the full cost of 
delivering services at the clinics. The intent of the waivers 
is to shift fragmented use from costly hospital emergency 
rooms and outpatient departments toward lower cost 
MHSP clinics that would provide beneficiaries with 
comprehensive primary and preventive health care. 

Status: MHSP waivers were scheduled to be terminated on 
December 31, 1984; however, HCFA agreed to extend the 
Medicare waivers through December 1985. With the 
passage of the Omnibus Budget Reconciliation Act 
(OBRA) of 1989, the demonstrations were extended to 
December 31, 1993. In addition, OBRA 1989 mandated 
that an independent evaluation regarding program cost 
effectiveness, beneficiary costs, quality of care, and other 
relevant factors be undertaken and that the findings of the 
evaluation be submitted in a report to Congress. HCFA 
contracted with Mathematica Policy Research, Inc. (MPR) 
to perform the independent evaluation. MPR reported that 
the MHSP program has grown since 1985 in terms of cost 
and use. The total gross of Medicare waiver services costs 
for the MHSP program from fiscal years 1985-92 was 
$225 million. A review of the MHSP cost reports 
indicated that a large proportion of the increase in 
program costs was caused by the rise in the use of high- 
cost ancillary services, such as prescription drugs, dental 
care, and vision care. OBRA 1993 again extended the 
demonstration through December 31, 1997. HCFA 
contracted with MPR to focus on the following three areas 
of inquiry which were not addressed in their 1993 study: 
impact to the Medicaid program, access to care, and 
utilization differences among different populations served 
by the demonstration sites. 

92-094 Nursing Home Payments by Source: 
Preliminary Statistics from the Medicare 
Current Beneficiary Survey 

(Formerly, Long-Term Care Studies (Section 207)) 

Project No.: 500-89-0047/32 

Period: May 1992-December 1994 

Funding: $ 55,500 

Award: Contract 

Principal 

Investigator: David Kennell 

Awardee: Lewin/VHI, Inc. 

(See page 17) 

HCFA Project Carolyn Rimes 

Officer: Division of Aging and Disability 

Description: Although national estimates of nursing home 
expenditures have been derived from various databases, 
direct estimates of the distribution of nursing home 
patients by the amount of payment and by the source of 



22 



Theme 1: Monitoring and Evaluating Health System Performance 



payment have not been derived. This study is the first 
attempt to utilize a major source of new information on 
nursing home payment, the Medicare Current Beneficiary 
Survey, to estimate these distributions. This study 
provides an indication of the differences in Medicaid and 
private nursing home payments for 1992. Variations in 
payments by nursing home characteristics are also 
presented and the findings were compared with the 
National Health Accounts. This work has been 
subcontracted to Korbin Liu of the Urban Institute. 

Status: This report has been submitted and is currently 
under review. 

94-005 Patterns of Utilization and Expenditures 
for Prescription Drugs in Selected State 
Medicaid Programs 

Project No.: 500-92-0020DO08 

Period: January 1994-July 1995 

Funding: S 236,705 

Award: Delivery Order in Master Contract 

Co-Principal 

Investigators: Rezaul Khandker, Ph.D., and 

Linda J. Simoni-Wastila, Ph.D. 
Awardee: Health Economics Research, Inc. 

(See page 193) 
HCFA Project Herbert A. Silverman, Ph.D. 
Officer: Division of Payment Systems 

Description: This project analyzed Medicaid data from 
eight States to describe patterns of prescription drug use 
and expenditures. The eight States were Alabama, 
California, Delaware, Georgia, Kentucky, Missouri, New 
Jersey, and Wyoming. The focus of the study was on the 
differential use of specific classes of drugs by classes of 
beneficiaries defined by demographic characteristics and 
program eligibility status. The impact of State 
administrative limits on prescription size and frequency of 
refills was also examined. 

Status: This project has been completed and a two-volume 
report submitted. Volume 1 contains an eight State 
comparative analysis. Volume 2 contains detailed State- 
by-State analysis of drug use and spending by 
demographic and program categories (e.g., basis of 
eligibility, medical assistance status). The specific 
objectives of this study were: 

• To examine Medicaid prescription drug spending at the 
State level as a proportion of total Medicaid spending 
and total outpatient spending. 

• To compare aggregate spending and utilization data 
across States that differ by reimbursement policies and 
spending levels. 

• To examine how spending and utilization levels vary by 
demographic characteristics and Medicaid eligibility 
groupings. 



• To determine how enrollment patterns (full-year, part- 
year continuous, and part-year discontinuous) affect 
spending and utilization rates. 

• To examine how spending varies by enrollment, 
demographic, and geographic variables across 
therapeutic drug categories. 

• To analyze patterns of geographic variation as 
determined by urban/rural status of counties. 

• To examine how States vary in spending and utilization 
of prescription drugs once demographic and eligibility 
mix of enrollees are controlled for; and 

• To examine the feasibility of using data from the 
Medicaid Statistical Information System (MSIS) in 
assessing prescription drug utilization and 
expenditures. 

The major findings of the study were: 

• Spending for prescription drugs as a percent of total 
Medicaid spending was highest for Missouri 

(12.3 percent) and lowest for Wyoming (4.8 percent). 
The average for all eight States was 9.7 percent. 

• Prescription drug spending as a percentage of total 
outpatient spending was highest in Missouri 

(27.8 percent) and lowest in Wyoming (12.2 percent). 
The average for all eight States was 24.7 percent. 

• Children generally had the lowest use and expenditure 
rates across all States and eligibility categories. Blind 
and disabled beneficiaries had the highest use and 
expenditure rates. 

• Prescription drug utilization increases with age. 
Children from the ages of 6-18 years of age used the 
least number of prescriptions, and, in most States, 
beneficiaries 75 years of age and over used the most. 

• Across all States, females used more drugs of every type 
(especially, psychoactive drugs) and incurred higher 
expenditures than males. 

• Consistently across all eight States, whites used more 
drugs and incurred higher expenditures than blacks and 
Hispanics. In a special analysis, black and white 
differences remained in Georgia even after controlling 
for age and basis of eligibility. The authors suggest the 
possibility of access barriers and/or race-based 
differences in disease and treatment patterns. 

• Although descriptive statistics show higher drug use 
and expenditure rates among rural beneficiaries relative 
to those in urban areas, multivariate analysis suggests 
that the difference reflects differences in demographic 
characteristics and basis of eligibility. When 
multivariate adjustments are made, beneficiaries in 
urban areas use more drugs and incur higher 
expenditures despite the fact that cost per prescription 
in the two areas was not different. 

• Full-year beneficiaries consistently used and incurred 
higher drug expenditure rates than part-year and 
discontinuous (multi-period) beneficiaries. Full-year 
beneficiaries tend to be disproportionately older, and 
this could account for some of the differences. 



Theme 1 : Monitoring and Evaluating Health System Performance 



23 



• Antibiotic and psychoactive drugs were the most 
frequently used drug categories across the eight States. 
Antibiotics were used more frequently by children up to 
18 years of age; psychoactive drug use increased with 
age and was highest among beneficiaries 45 to 64 years 
of age. These two classes of drugs also accounted for 
the highest expenditures in the eight States. 

• Efforts to identify the impact of State drug policies on 
the use of and expenditures for drugs produced 
ambiguous findings, and the data do not support any 
clear relationship between State drug policies and drug 
use and expenditures. It is believed that the sample 

of eight States was too small to produce unambiguous 
findings. 

The two volumes are available from the National 
Technical Information Service. The accession numbers 
are Volume 1, PB96-155171 and, Volume 2: PB96- 
155189. 

94-085 Predictors of Access and Effects of 
Medicare Post-Hospital Care for Beneficiaries 
65 Years of Age and Over 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



17-C-90395/3 

September 1 994-September 1996 

$ 502,614 

Cooperative Agreement 

David L. Rabin, Ph.D. 

Georgetown University 

Division of Community Health Studies 

and Family Medicine 

3750 Reservoir Road, NW. 

Washington, DC 20007-2197 

Carolyn Rimes 

Division of Aging and Disability 



Description: As a consequence of regulatory and 
legislative changes in the late 1980s, Medicare post- 
hospital care (PHC) has become the most rapidly growing 
Medicare expenditure. PHC consists of home health care, 
inpatient skilled nursing facility care, and rehabilitation 
hospital care. The growth in use, changes in eligibility 
requirements, and the increase in Medicare costs have 
raised questions about equal access and the effects of PHC 
use. The literature on PHC suggests two important trends. 
A few Medicare prospective payment inpatient hospital 
diagnosis-related-groups (DRG) account for most PHC, 
but within these DRGs large variations exist in use. 
Personal health, economic, sociodemographic, and 
household factors, as well as area and health system 
characteristics, are predictive of the use of PHC despite 
equal access under the Medicare program. This study uses 



the Medicare Current Beneficiary Survey to investigate 
three major research objectives: 

• Describe the personal, area, and health system 
characteristics of users and those of similar persons 
with unmet needs for PHC in order to assess differences 
by gender, race, and income class and the potential for 
substitution of care modes. 

• Study the longitudinal effects of PHC on Medicare 
program costs an rehospitalization. 

• Study the personal health effects associated with PHC. 

Status: Because of the delay experienced in releasing the 
Medicare Beneficiary Cost and Use File and the 
dependence of this project on the Medicare Current 
Beneficiary Survey Data, this project is initiating the data 
analysis phase. The final report is expected to be 
completed in June 1997. 

95-094 Quality Assurance for Phase II of the Home 
Health Agency Prospective Payment Demonstration 

Project No.: 500-95-0028 

Period: September 1995-September 2000 

Funding: $ 2,799,265 

Award: Contract 

Principal 

Investigator: Peter W. Shaughnessy, Ph.D. 

Awardee: Center for Health Policy Research 

1355 South Colorado Boulevard 

Suite 306 

Denver, CO 80222 
HCFA Project Phyllis A. Nagy, MHS 
Officer: Division of Aging and Disability 

Description: This contract provides for developing and 
implementing a quality review mechanism for use by 
home health agencies (HHAs) participating in Phase II of 
the Home Health Agency Prospective Payment 
Demonstration. This demonstration is testing two 
alternative methods of paying HHAs on a prospective 
basis for services furnished under the Medicare program. 
The prospective payment approaches being tested include 
payments per visit by type of discipline (Phase I), and 
payments per episode of Medicare-covered home health 
care (Phase II). To ensure that incentives created under 
Phase I did not result in the provision of inadequate care 
to Medicare beneficiaries, the New England Research 
Institute, Inc. (NERI) implemented a quality assurance 
(QA) approach that utilized patient record reviews for a 
sample of Medicare beneficiaries. However, since one of 
the goals of Health Care Financing Administration's 
Medicare Home Health Initiative is to move toward the 
implementation of an outcome-based, patient-centered 
(QA) system for Medicare home health, it was felt that the 
second phase of this demonstration provided an 
opportunity to incorporate a scaled-down version of the 



24 



Theme 1: Monitoring and Evaluating Health System Performance 



outcome-based program developed by the Center for 
Health Services Research at the University of Colorado. 

Status: During the first project year, the contractor 
developed software for electronic submission of (QA) data 
from participating home health agencies, completed 
preliminary agency training, initiated the collection of 
(QA) data, developed and implemented a data receipt 
tracking and control system, and has continued to provide 
additional technical assistance and retraining for agencies 
as necessary. 

94-006 Quality of Care: Medicaid and 
Other Populations 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandate: 



500-94-0017 

June 1994-December 1996 

$ 439,857 

Contract 

Nancy Merrick, M.D. 
SysteMetrics, Inc. 
Santa Barbara Corporate Center 
5425 Hollister Avenue, Suite 140 
Santa Barbara, CA 93 1 1 1 
M. Beth Benedict, Dr.P.H. 
Division of Health Information 
and Outcomes 

Omnibus Budget Reconciliation Act 
of 1986 (Public Law 99-509) 



Description: The purpose of the project is to analyze a 
medical records data set to assess medical necessity, 
appropriateness, and effectiveness (outcomes) of selected 
treatments and procedures in the Medicaid and privately 
insured populations in response to the congressional 
mandate (Public Law 99-509). The database includes 
records of emergency room and inpatient care for 
pediatric asthma, inpatient hysterectomy, and complicated 
labor and delivery (which includes records of mothers and 
their newborns). A secondary data analysis is to be 
conducted of the outcomes of a sample of Medicaid 
pediatric asthma patients enrolled in managed-care plans 
compared to a sample receiving care through regular fee- 
for-service arrangements. This contract builds on the 
Health Care Financing Administration's quality-of-care 
research agenda in the context of health care reform. 

Status: A draft report is under review. 

93-097 Regional Variation in Home Health Episode 
Length and Number of Visits Per Episode (Formerly, 
Long-Term Care Studies (Section 207)) 

Project No.: 500-89-0047/38 

Period: July 1 993-November 1994 

Funding: $ 168,600 



Award: 
Principal 
Investigator: 
Awardee: 

HCFA Project 
Officer: 



Contract 

David Kennell 

Lewin/VHI, Inc. 

(See page 17) 

Carolyn Rimes 

Division of Aging and Disability 



Description: This study focused on two questions: 

• Why does the use of home health care vary across the 
regions? 

• Is there a corresponding variation across the regions in 
patient outcomes suggesting that lower levels of care 
lead to poorer outcomes for patients, or that higher 
levels lead to improved outcomes? 

This study used the Medicare claims files, the provider of 
services file, the area resource file, and the regional Home 
health intermediary database to determine the 
contribution of three sets of factors to regional variation. 
These sets of factors are patient characteristics, supply of 
home health agencies and staff, and availability of 
alternatives to home health care. 

Status: The final report has been received and is under 
review. 

91-101 Synthesis of the Nursing Home Bed Supply 

(Formerly, Long-Term-Care Studies (Section 207)) 

Project No.: 500-89-0047/23 

Period : May 1 99 1 -September 1 994 

Funding: $ 49,000 

Award: Contract 

Principal 

Investigator: David Kennell 

Awardee: Lewin/VHI, Inc. 

(See page 17) 

HCFA Project Carolyn Rimes 

Officer: Division of Aging and Disability 

Description: Analyses have shown that there is excess 
demand for nursing home care. Part of this excess 
demand is attributed to State-imposed constraints on the 
supply of nursing home beds. States have imposed these 
supply constraints in an attempt to control their Medicaid 
budgets and to redirect resources from institutional to 
noninstitutional care. This synthesis addresses: 

• How much variation is there in the supply of nursing 
home beds? 

• Why do variations in the supply of beds exist across 
States? 

• To what extent does a State's capital reimbursement 
system encourage/discourage sufficient investment of 
capital to meet its demand for new beds? 

• What is the relationship between certificate of need and 
capital replacement? 



Theme 1: Monitoring and Evaluating Health System Performance 



25 



• What is "excess demand" and how is it measured? 

Status: This report found that much of the attention paid 
to the adequacy of a State's supply of nursing home beds 
focuses on the effect that supply has on access to care and 
often ignores important demand-side issues. One of these 
issues, the subsidization of health care expenses for 
Medicaid beneficiaries, results in excess demand for 
nursing home services by Medicaid beneficiaries, who are 
encouraged to demand more services than they otherwise 
would. This study found that, in general, access problems 
do not exist for private patients. However, access 
problems do exist for some Medicaid beneficiaries, 
especially for heavy-care persons with head injuries, with 
behavioral problems, or who need ventilators. Since each 
State has a unique long-term-care system, measures of the 
adequacy of the supply of nursing home beds in one State 
may not accurately measure the adequacy of supply in 
another State. Furthermore, given the differences in 
programs, laws, and market conditions across States, 
policies that help control long-term-care expenses in one 
State may not necessarily be appropriate for other States. 

91-103 Synthesis of Reimbursement Options 

(Formerly, Long-Term-Care Studies (Section 207)) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-89-0047/10 
September 1991-January 
S 77,600 
Contract 



1996 



David Kennell 

Lewin/VHI, Inc. 

9302 Lee Highway, Suite 500 

Fairfax, VA 22031-1207 

Carolyn Rimes 

Division of Aging and Disability 



Description: The purpose of this synthesis is to assist the 
Health Care Financing Administration and other relevant 
policymakers in answering specific questions concerning 
nursing home reimbursement. The first part of the 
synthesis is organized into four sections — summary, 
overview of the Medicaid reimbursement system and State 
policy goals, design of the details of a reimbursement 
system, and analysis of options for capital reimbursement. 
The second part is organized into two sections: 

• Synthesis of research studies relevant to modifying the 
current method by which skilled nursing facilities 
(SNF) receive payment under Part A of the Medicare 
program. 

• Synthesis of research studies relevant to replacing the 
current system with a system under which Medicare 
SNF payment would be made on the basis of 
prospectively determined rates. 



Status: A draft report has been received. The final report 
is expected to be completed in January 1997. 

91-102 Synthesis of Unmet Need for 
Long-Term-Care Services (Formerly, 
Long-Term Care Studies (Section 207)) 

Project No.: 500-89-0047/29 

Period: June 1991-August 1995 

Funding: $ 27,400 

Award: Contract 

Principal 

Investigator: David Kennell 

Awardee: Lewin/VHI, Inc. 

(See page 17) 

HCFA Project Carolyn Rimes 

Officer: Division of Aging and Disability 

Description: The purpose of this study is to conduct a 
literature review and prepare a synthesis of previous work 
in the area of unmet need for long-term-care services. 
This project concentrated on identifying unmet need using 
secondary analysis of survey data. Included is an analysis 
of data from the National Long-Term Care Surveys, the 
1984 Supplement on Aging, the Longitudinal Study of 
Aging, and the Channeling demonstration projects. This 
study explores possible measures that can be constructed 
from national databases to assess unmet need for long- 
term-care services. The study evaluates the merits of 
alternative measures, establishes definitions of unmet 
need, using survey data, and then develops a framework 
for comparing this analytic work with earlier studies. This 
work was completed by Barbara Lyons of the Johns 
Hopkins University School of Hygiene and Public Health 
under subcontract to Lewin/VHI, Inc. 

Status: The final report has been received and is under 
review. 

95-046 Understanding Properties of the 
Unique Physician Identification Number (UPIN) 
for Claims-Based Research 

Project No.: 500-92-0020DO14 

Period: August 1 995-December 1996 

Funding: $ 177,063 

Award: Delivery Order in a Master Contract 

Principal 

Investigator: Killard W. Adamache, Ph.D. 

Awardee: Health Economics Research, Inc. 

(See page 193) 

HCFA Project Ann Meadow, Sc.D. 

Officer: Division of Payment Systems 

Description: The Health Care Financing Administration 
(HCFA) assigns a single, national unique physician 
identification number (UPIN) to each physician who 



26 



Theme 1: Monitoring and Evaluating Health System Performance 



provides non-health maintenance organization (HMO) 
services under the Medicare program. Originally 
mandated by Congress to safeguard program funds, the 
UPIN has growing potential as a research tool — for 
studies of health manpower, access to care, payment 
methods, provider behavior, and other health services 
research issues. The purposes of this delivery order are to: 

• Investigate the strengths and limitations of the UPIN as 
a research tool — one which has been implemented 
within a complex, decentralized administrative system 
oriented primarily to health care claims processing. 

• Improve and extend the research-related properties of 
the UPIN and successor identifiers in the future. 

• Develop background information for supporting 
HCFA's move to a national electronic claims- 
processing and practitioner/supplier enumeration 
system. 

The project tasks include analyzing data from claims and 
physician-enumeration files to assess their accuracy and 
completeness; gathering background information on 
carrier operations that have significance for interpreting 
UPIN-related data; and conducting discussions with 
selected State licensing boards about license number 
assignment and technologies with potential to support 
license verification procedures. 

Status: The contractor has completed the following tasks: 
interviews with three peer review organizations (PROs) 
concerning their experiences with UPIN-related data; 
preliminary analyses to document data patterns and 
problems for use in the carrier case studies and in the 
discussions with State licensing boards; carrier case 
studies; discussions with State licensing boards; analyses 
of the accuracy and completeness of Part B referring- 
physician UPIN reporting; and the project's Interim 
Report, "Understanding Properties of the UPIN for 
Claims-based Research: Final Interim Report," 
October 21, 1996. 

The PRO interviews revealed a useful role for the UPIN 
identifier in claims when PROs attempted to associate 
Part B claims to individual physicians under study. 
However, the PROs did report encountering UPIN 
inaccuracies on claims, multiple physicians assigned to 
one UPIN, as well as physicians having more than one 
UPIN. They were unable to quantify the frequency of such 
problems. The preliminary analyses' investigation of the 
correspondence between billing numbers on National 
Center for Health Statistics Part B claims and on the 
Registry found that the claim billing numbers often could 
not be found on the Registry. This implied that research 
to study service delivery at the physician's practice-setting 
level would be difficult to undertake, except in a relatively 
small number of carrier areas. For claims where the 
billing number/UPIN combination was matched to the 
Registry, a comparison of record accretion dates to the 



Registry and service dates on claims found that several 
carriers had substantial numbers of services associated 
with date discrepancies. This suggested that physician 
billing from a practice-setting was occurring in the 
absence of a current record for that setting. The State 
license number analyses found significant numbers of 
cases of multiple license numbers for a single UPIN or 
multiple UPINs for a single license number, whereas there 
should be a unique relationship between the UPIN and 
license number. The carrier case studies indicated that 
carriers vary considerably in their criteria for establishing 
practice-setting records in their provider files and in the 
UPIN Registry. The case studies also suggested how 
certain claims-processing procedures can result in 
discrepancies between claims and Registry data, and how 
limitations of data entry edits can allow errors in Registry 
data. The examination of referring-physician UPINs 
found that about 77 percent of Part B line items had a 
valid referring-physician UPIN and, including self- 
referrals, 98 percent of the line items subject to Common 
Working File edits had a valid referring UPIN. 

92-040 Validation of Nursing Home Quality Indicators 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-90090/9 

July 1992-September 1996 

$ 990,094 

Cooperative Agreement 

Susan A. Flanagan, MPH 

MedStat Group 

104 West Anapamu Street 

Santa Barbara, CA 93101 

Kay Lewandowski 

Division of Aging and Disability 



Description: This project is a continuation of a 
cooperative agreement to investigate the usefulness of 
claims data from Medicaid and Medicare administration 
record systems as sources of nursing home quality-of-care 
measures. The previous study involved retrospective 
analysis of 1987 Medicaid and Medicare claims data and 
facility deficiency data from Michigan and Tennessee. 
The objective of the current project is to validate these 
resident-level claims-based quality-of-care indicators 
(QCI) by recomputation of the claims-based indicators for 
California and Georgia using data for 1990. To complete 
the validation process, a sample of residents in a sample 
of nursing homes will be drawn for these two States, and 
the medical records for these patients will be reviewed by 
a team of physicians and nurses. The results of the record 
review will then be compared with the findings of the QCI 
algorithms to test the relationship of the QCIs to cited 
deficiencies and adverse outcomes. 

Status: This project has completed collection of medical 
record data from California and Georgia, and the data has 



Theme 1 : Monitoring and Evaluating Health System Performance 



27 



been reviewed by nurse and physician evaluators. Initial 
analysis had been completed and a draft report of early 
study findings has been submitted. The final report is 
expected in early 1997. 

Intramural 

IM-057 Cancer Retreatment Rate after 
Radical Prostatectomy in Patients Diagnosed 
with Clinically Localized Prostate Cancer 

Funding: Intramural 

HCFA Project Grace L. Lu-Yao, Ph.D. 
Director: Division of Health Information and 

Outcomes 

Description: Radical prostatectomy is one of the most 
commonly used curative procedures for localized prostate 
cancer. However, the probability of requiring additional 
cancer treatment after this procedure is largely unknown. 
The objective of this study is to provide estimates 
regarding the likelihood of requiring additional cancer 
therapy after radical prostatectomy in geographically 
defined populations. This study was based on a linked 
data set that combined information from the Surveillance, 
Epidemiology, and End Results program and the 
Medicare hospital and physician claims. Patients were 
considered to have additional cancer treatment if there 
was evidence of radiation therapy, orchiectomy, and/or 
androgen deprivation therapy by injection. Overall, the 
5-year cumulative incidence of having any additional 
cancer treatment after radical prostatectomy reached 
34.9 percent. For patients with a pathological organ- 
confined cancer, the 5-year cumulative incidence of 
additional treatment ranges from 15.6 percent for well- 
differentiated cancer to 41.5 percent for poorly 
differentiated cancer. The corresponding figures for 
patients with pathologically regional cancer are 
22.7 percent and 68.1 percent. 

Status: The study was presented in the 1995 national 
conference of American Urological Association and 
American Federation of Clinical Research and was 
featured in the Journal of National Cancer Institute 
(February 1996) with the following citation: Lu-Yao, 
G.L., Potosky, A. L., Albertsen, P. C, Wasson, J. H.; 
Barry, M. J., and Wennberg, J. E.: "Follow-up Prostate 
Cancer Treatments after Radical Prostatectomy: 
A Population-Based Study." 

IM-022 Data Support Activities 

Funding: Intramural 

HCFA Project Charles R. Helbing 

Director: Division of Data Systems and Resources 

Description: This project provides data processing, 
graphics, desktop publishing, and statistical support 



services to assist analysts and researchers in developing 
and disseminating a wide variety of Office of Research 
and Demonstrations projects, congressional mandates, 
health care policies and legislative initiatives, and data 
dissemination activities. Some activities this project is 
involved in are Reports to Congress, Health Care 
Financing Review articles, presentations and seminars, 
special studies, internal reports, and press releases. 

Status: This intramural project produces and disseminates 
current and relevant Medicare and Medicaid data on an 
ongoing basis. The output is maintained on computer 
mass storage and data diskettes. The statistical data and 
related information are available on request. 

IM-034 Determinants of Home Health Use 

Funding: Intramural 

HCFA Project Elizabeth Mauser, Ph.D. 

Director: Division of Aging and Disability 

Description: Modifications in the eligibility requirements 
for Medicare home health services, implementation of the 
Medicare prospective payment system in hospitals, and 
beneficiary preferences to remain in the community have 
resulted in significant increases in Medicare home health 
care expenditures. Although Medicare home health 
expenditures continue to rise, relatively little is known 
about home health users and the market characteristics 
that affect home health use. Consequently, the Health 
Care Financing Administration has implemented several 
intramural research studies to support future efforts of 
payment reform in the area of post-acute care. Using the 
Medicare Current Beneficiary Survey (MCBS) and home 
health claims data, this study is exploring the following 
issues: 

• Whether home health users can be classified into 
distinct subgroups to understand the special care needs 
of home health users, determine how specific policies 
affect different groups of users, and develop case-mix 
adjustments for payment reform. 

• How home health use has changed over time, using the 
1991, 1992, and 1993 MCBS. 

• The effect of supply factors on home health use by 
linking the MCBS with the area resource file. 

• The extent of substitution among different post-acute 
care settings, such as skilled nursing, home health, and 
rehabilitation facilities. 

Status: Using the 1992 MCBS, the characteristics of 
beneficiaries using Medicare home health were examined 
and multivariate models were developed to determine the 
factors that affect use and expenditures. Based on this 
work, "A Profile of Home Health Users in 1994," by 
Mauser, E., and Miller, N. A., appeared in the Fall issue 
of the Health Care Financing Review, Volume 16, 
Number 1, pp. 17-33, 1994. An analysis has been 



28 



Theme 1 : Monitoring and Evaluating Health System Performance 



completed regarding the effect of organizational form on 
home health use. Based on this work, an article has been 
prepared to be presented at the American Public Health 
Association Meetings. (This work suggests that for-profit 
home health agencies provide close to 21 visits more per 
year to home health users). Additionally, using home 
health claims data from 1993-95, as well as Cycle 12 
data, an analysis looking at the impact of organizational 
form, pre-home health location, and individual 
characteristics on episode length and monthly home 
health costs has been completed and will be presented at 
the American Public Health Association Meetings in 
November 1996. 

IM-050 Disenrollment of Medicare 
Cancer Patients from HMOs 

Funding: Intramural 

HCFA Project Gerald F. Riley and James D. Lubitz 
Director: Division of Health Information and 

Outcomes 

Description: There is concern that financial incentives in 
health maintenance organizations (HMOs) might result in 
pressures to induce sicker members to disenroll. The study 
compared disenrollment rates of Medicare HMO enrollees 
with cancer to disenrollment rates for cancer-free 
enrollees, using Medicare enrollment files linked to 
population-based tumor registry data from the 
surveillance, epidemiology, and end results (SEER) 
program. 

The study identified all aged Medicare beneficiaries who 
enrolled in an HMO in a SEER reporting area during 
1985-89. Time from enrollment to disenrollment was 
analyzed by using a Cox proportional hazards model. The 
analysis controlled for age, sex, race, and Medicaid status. 
Enrollees were followed for up to 18 months after a 
diagnosis of cancer. 

Status: The study has been published in Medical Care. 
Citation: Riley, G. F., Feuer, E. J., and Lubitz, J. D.: 
"Disenrollment of Medicare Cancer Patients from Health 
Maintenance Organizations." Medical Care, Volume 34, 
Number 8, pp. 826-836, August 1996. 

IM-038 Drug Patent Expirations and the 
Speed of Generic Entry 



Funding: 
HCFA Project 
Director: 



Intramural 

Jay Bae, Ph.D. 

Division of Payment Systems 



Description: When patents expire on prescription drugs, 
other firms may market chemically identical versions as 
generic drugs. This project examines the phenomenon of 
generic drug entry between 1987 and 1994. Recognizing 
the entry phenomenon as a dynamic process that occurs 



over time, this study evaluates the entry and non-entry 
cases in a duration model. The estimation resulted in the 
following findings: 

• There is a negative relationship between the innovative 
drug's sales revenue and the time to generic entry. In 
other words, the drugs that generate more revenue 
attract more rapid generic entries. 

• The drugs that primarily treat chronic symptoms have 
quicker entries than the types of drugs that primarily 
treat acute illness. 

• The generic entries became less likely and the time 
delay increased during the data period. This is a 
reversal of the trend observed between 1983 and 1987 
by Grabowski and Vernon. 

• Entry barriers for generic drugs seem to be non- 
monotonic in the number of existing branded products 
in a therapeutic market. 

Status: The final report is under revision. 

IM-042 Effects of Insurance on Medical Spending 
Growth and the Determinants of Insurance Coverage 

Funding: Intramural 

HCFA Project Edgar A. Peden, Ph.D. and 

Directors: Mark S. Freeland, Ph.D. 

Division of Payment Systems and 
Office of National Health Statistics 

Description: This project uses National Health Account 
data (1960 to 1993) to examine the effects of aggregate 
insurance coverage (the percentage of medical spending 
covered by third parties) on technology and real per capita 
medical spending growth in the United States. As a 
follow-up, it examines the determinants of insurance 
coverage itself. Results from the project have been used by 
the Health Care Financing Administration's Office of the 
Actuary to assess the effects of various policy alternatives 
regarding coverage and medical spending. 

Status: The project has produced theoretical and empirical 
results regarding the impact of insurance coverage and 
other factors on medical spending growth. These results 
have been published in Health Affairs, Summer 1995, as a 
Data Watch item, "A Historical Analysis of Medical 
Spending Growth, 1960-1993." Work is continuing on a 
technical version of this study, and this year a paper has 
been submitted to an economics journal. Work on the 
determinants of insurance coverage is in a nascent stage. 

IM-055 Evaluating the Effects of Physician 
Payment Reform on Access: Time-Series Analyses of 
Hospitalizations for Ambulatory Care Sensitive 
Conditions 



Funding: 



Intramural 



Theme 1 : Monitoring and Evaluating Health System Performance 



29 



HCFA Project Thomas W. Reilly, Ph.D. 
Director: Division of Health Information and 

Outcomes 

Description: This project evaluates the effects of physician 
payment reform (PPR) on access to care in the Medicare 
population by studying patterns of hospitalization for 
ambulatory care-sensitive (ASC) conditions. If there is a 
decrease in access to needed ambulatory care services 
associated with PPR, one would expect to see an increase 
in hospitalizations for ASC conditions following the 
implementation of PPR. This project will analyze the 
trend in rates of hospitalization for selected ASC 
conditions to see whether there is a discontinuity in the 
time series associated with the implementation of PPR. 

Status: The analysis has been completed and a paper 
was published in the Health Care Financing Review, 
Volume 17, Number 2, pp. 179-194, March 1996, HCFA 
Publication Number 03380. 

IM-005 Financial Ratios: Implications for Assessment 
of Hospital Profitability and Efficiency 



Funding: 
HCFA Project 
Director: 



Intramural 

William Buczko, Ph.D. 

Division of Payment Systems 



Description: This project examines the utility of financial 
ratios for assessment of hospital financial status and 
compares several ratios measuring aspects of financial 
performance using Medicare Cost Report data. 

Status: Analysis of Medicare patient margin and total 
facility margin data to assess hospital profitability is 
ongoing. "Allowances on Patient Accounts and Hospital 
Profitability," a paper examining discounting of patient 
charges and its effect on hospital financial performance, 
was presented at the 1995 Annual Meeting of the 
American Public Health Association. Further research 
will examine additional financial indicators using updated 
cost report data. 

IM-006 Longevity and Medicare Expenses (Formerly, 
Lifetime Medicare Costs by Time on Medicare) 

Funding: Intramural 

HCFA Project James D. Lubitz and 

Judith A. Sangl, Sc.D. 
Director: Division of Health Information and 

Outcomes 

Description: Little is known about the relationship 
between longevity and lifetime Medicare costs. This study 
uses the Continuous Medicare History Sample, a 
longitudinal file covering years 1974-90, to estimate 
Medicare payments for persons dying from 65 years of 



age to over 100 years of age. It simulates lifetime 
Medicare payments under various future longevity 
scenarios. 

Status: The results of the study were published in an 
article, "Longevity and Medicare Expenditures" in the 
April 13, 1995 issue of the New England Journal of 
Medicine. The study found that, compared to the large 
effect on Medicare expenditures from increased number of 
enrollees, increased longevity will have relatively little 
effect on the Medicare budget. 

A follow-up study, conducted in collaboration with the 
Agency for Health Care Policy and Research, is 
examining lifetime expenses for all health care services 
for the elderly, including Medicare-covered services, 
nursing home services, prescription drugs, and home 
health care. Expenses under different longevity scenarios 
will be simulated. The study will also examine patterns 
of health care expenses in the last years of life for various 
services. 

IM-001 Medicare and Medicaid Statistical 
Supplement: Health Care Financing Review 

Funding: Intramural 

HCFA Project Charles R. Helbing 

Director: Division of Data Systems and Resources 

Description: The Annual Supplement of the Health Care 
Financing Review presents comprehensive data on the 
experiences of the Medicare and Medicaid programs. 
Each issue will contain the following: 

• Extensive graphic presentations of longitudinal and 
cross-sectional data describing the demographic 
characteristics of program beneficiaries, patterns of 
service utilization, and program expenditures for the 
Medicare and Medicaid programs. 

• Description of the eligibility criteria, benefit structures, 
and payment methods of the Medicare and Medicaid 
programs. 

• Detailed longitudinal and cross-sectional tables 
describing the number and characteristics of Medicare 
and Medicaid beneficiaries, the use of Medicare and 
Medicaid benefits, and the amounts and distributions of 
program payments by State, demographic 
characteristics, and service type. 

Status: The 1996 Annual Supplement has been published 
(September 1996). The 1997 Annual Supplement is 
expected to be published in Fall 1997. This issue will 
contain Medicaid data for fiscal year 1995 and Medicare 
data for calendar year 1995. The Supplement may be 
obtained by subscribing to the Health Care Financing 
Review. Each subscription costs $30.00 per year, 
domestic; $37.50, foreign. Single issues of the 



30 



Theme 1: Monitoring and Evaluating Health System Performance 



Supplement cost SI 9.00. domestic; S23.75, foreign. 
Single copies and subscriptions may be obtained from the 
Superintendent of Documents, Post Office Box 371954, 
Pittsburgh, Pennsylvania 15250-7954. 

IM-037 Medicare HMO Evaluation 

Funding: Intramural 

HCFA Project Cynthia G. Tudor. Ph.D.. 

Directors: Mel Ingber, Ph.D., Gerald F. Riley, 

and Jay Bae, Ph.D. 

Division of Delivery Systems and 

Financing 

Description: To assess and monitor the Medicare risk 
program, the Office of Research and Demonstrations has 
established an ongoing health maintenance organization 
(HMO) evaluation program, examining a number of 
critical issues, including selection and savings, 
disenrollment patterns, the effect of managed care on 
costs in the fee-for-service sector (i.e., spillover), 
beneficiary satisfaction, and quality of care. This 
evaluation will also update the findings from an earlier 
study of the Medicare risk HMO program, conducted by 
Mathematica Policy Research, Inc. That study found that 
the Health Care Financing Administration paid 
5.7 percent more for HMO enrollees than would have 
been spent on them under fee-for-service (FFS). 

Status: Initial findings from the selection and savings 
study suggest that HMO enrollees tend to be healthier 
than beneficiaries in fee-for-service. The problem of 
overpayments documented in the Mathematica evaluation 
has not improved with the recent expansion of Medicare's 
risk contracting program. These findings suggest that 
Medicare continues to overpay HMOs for its enrollees. 
Other findings will be available in mid- 1997. 

IM-036 Medicare SELECT Demonstration 
Program Evaluation: Report to Congress 



Funding: 
HCFA Project 

Director: 



Mandate: 



Intramural 

Sherry A. Terrell. Ph.D. 
Division of Delivery Systems 
and Financing 

Omnibus Reconciliation Act of 1990 
(Public Law 101-508) 



Description: The Secretary of the Department of Health 
and Human Services is required by section 4358(d) of the 
Omnibus Budget Reconciliation Act of 1990 to report to 
Congress on the 15-State Medicare SELECT 
demonstration of an experimental Medicare supplemental 
insurance product which was allowed to be sold in 
Alabama, Arizona. California. Florida, Illinois, Indiana, 
Kentucky, Massachusetts, Minnesota, Missouri, North 



Dakota, Ohio, Texas, Washington, and Wisconsin 
between January 1992 and December 1994. Congress 
subsequently extended the experiment for 3 years and 
expanded it to all States that might wish to participate. 

Status: A letter Report to Congress was submitted on 
May 22, 1996, summarizing the following evaluation 
issues — implementation; consumer access, satisfaction, 
and informed consent; premium affordability; and impact 
on Medicare program costs. Evaluation findings produced 
mixed results. As of November 1, 1995, there were 
approximately 489,000 Medicare beneficiaries enrolled in 
SELECT plans in 14 demonstration States, representing 
about 2.8 percent of Medicare beneficiaries in those 
States. Implementation of SELECT varied significantly in 
many of the states from the implicit legislative model. 
Access to services and satisfaction with policies was the 
same for both Medicare SELECT and standard Medigap 
policyholders. In the first 3 years of the SELECT 
demonstration, Medicare program costs increased in 
5 participating States (Alabama. Arizona, Indiana, Texas, 
and Wisconsin), decreased in 4 States (California, 
Florida, Missouri and Ohio), and were not affected in 
2 States (Kentucky and Minnesota). Cost increases were 
generally related to Part B utilization. In regard to costs to 
beneficiaries, in 1994 and 1995 SELECT enrollees 65 
years of age generally were offered lower premiums than 
beneficiaries who purchase the same (A-J) standard 
Medigap policy issued by the same insurer. However at 
75 years of age, SELECT enrollees faced more expensive 
SELECT premiums than those of comparison community 
rated products during the study period, likely reflecting 
the practice of some SELECT plans of selling attained- 
age policies. 

IM-053 Monitoring Access to Physician Services 
Among Vulnerable Subgroups of the Medicare 
Population: Controlling for the Underlying Need 
for Services 

Funding: Intramural 

HCFA Project Thomas W. Reilly, Ph.D. 

Director: Division of Health Information and 

Outcomes 

Description: A number of prior studies have attempted to 
evaluate access to physician services under Medicare by 
examining group differences in patterns of use. The 
problem with such analyses is that one often does not 
know whether differences in use reflect differences in 
access to care or differences in the underlying need for 
services. This project will isolate differences in access by 
comparing patterns of use within populations with 
comparable need for services. It will begin by examining 
the probability of obtaining follow-up care after a 
hospitalization for congestive heart failure. Since all such 
patients should receive a follow-up visit with a physician 



Theme 1: Monitoring and Evaluating Health System Performance 



31 



within 30 days, differences in follow-up care more clearly 
reflect differences in access rather than differences in the 
underlying need for services. The project will especially 
focus on whether potentially vulnerable subgroups are less 
likely to obtain needed care. 

Status: The study is in the design phase. 

IM-052 Monitoring Changes in Self-Reported Access 
to Care Among Medicare Beneficiaries 

Funding: Intramural 

HCFA Project Thomas W. Reilly, Ph.D. 
Director: Division of Health Information and 

Outcomes 

Description: Efforts to monitor access in Medicare need to 
include information from beneficiaries on their 
experiences in obtaining care covered by the program. 
This study will examine data from the Medicare Current 
Beneficiary Survey on issues such as availability of care 
and perceived barriers to care. The study will track 
responses over time for the overall Medicare population 
and for potentially vulnerable subgroups. 

Status: The study is in the design phase. 

IM-054 Monitoring Needs Not Met by Medicare: 
An Examination of the Use of Non-Covered 
Services Among Medicare Beneficiaries 

Funding: Intramural 

HCFA Project Thomas W. Reilly, Ph.D. 
Director: Division of Health Information and 

Outcomes 

Description: One important aspect of access to care for 
Medicare beneficiaries involves the extent to which 
needed services are, or are not, covered by the program. 
This project will monitor the use of non-covered services 
among Medicare beneficiaries, using data from the 
Medicare Current Beneficiary Survey. It will identify 
areas of high use/expenditure for the overall Medicare 
population and for potentially vulnerable subgroups. 
These analyses will help identify important gaps in 
Medicare coverage and identify subgroups of beneficiaries 
with relatively high levels of need for services not 
currently covered by the program. Tracking changes in 
patterns of use over time will help identify areas of 
growing need unmet by Medicare. 

Status: The study is in the design phase. 

IM-010 Monitoring Utilization of and Access to 
Services for Medicare Beneficiaries under 
Phvsician Payment Reform 



Funding: 



Intramural 



HCFA Project Ann Meadow, Sc.D. 
Director: Division of Payment Systems 

Mandate: Omnibus Budget Reconciliation Act 

of 1989 (Public Law 101-239) 

Description: The Social Security Act, as amended by the 
Omnibus Budget Reconciliation Act of 1989, specified a 
new payment system for Medicare physicians' services. 
This intramural project is one of several analyzing effects 
of the new system on access to care. The work focuses on 
access impacts of the Medicare fee schedule (MFS) from 
the perspective of the physician. Although population- 
based use data can measure access as an outcome, such 
information does not explain the process by which 
physicians respond to policy change and thereby influence 
access. This project analyzed all available Medicare 
Part B claims from a panel of physicians identified by 
their unique physician identification number (UPIN). The 
first phase of the study analyzed 2 years of data (1991-92) 
from a panel comprising 7,361 physicians in 18 selected 
States. The second phase analyzed 2 years of data 
(1992-93) from a dynamic panel of approximately 18,000 
physicians in 36 States, and included allowed-charge data 
from 100 percent of physicians in 29 of those States. 
Additionally, the study examined 3-year trends in 
15 States with claims data adequate for analysis back to 
1991, which was the final year before implementation of 
the MFS. The study's emphasis in the first two phases 
was on measuring change in several key access-related 
measures. The measures were caseload (i.e., number of 
beneficiaries treated in a year), continuity in performing 
specific procedures, total allowed charges, and assigned 
charges as a proportion of allowed charges. The third 
phase, conducted in 1996, was limited to review of 
caseload and allowed charges for 1992-94. 

Status: First- and second-phase findings were included in 
two successive Reports to Congress, "Monitoring the 
Impact of Medicare Physician Payment Reform on 
Utilization and Access" (1994 and 1995). A review of 
selected findings for 1991-93 was published in the Winter 
1 995 issue of the Health Care Financing Review, "Access 
to Care Under Physician Payment Reform: A Physician- 
Based Analysis." 

The study's third phase showed that the overall average 
caseload from the 36 study areas grew about 2 percent 
between 1993 and 1994. This growth rate is similar to the 
modest gain estimated for 1992-93, which was 
3 percent. The median caseload continued to increase 
between 1992 and 1994. Subtotals for six major specialty 
categories— primary care; psychiatry; medical specialties; 
a group combining radiology, anesthesiology, and 
pathology (RAP); surgical specialties; and limited license 
practitioners — suggested that between 1993 and 1994 
surgeons and limited license practitioners (LLPs) 



32 



Theme 1 : Monitoring and Evaluating Health System Performance 



registered above-average, statistically significant gains in 
mean caseload — gains of 4 percent and 6 percent, 
respectively. In both cases, this appears to contrast with 
flat growth experienced during the 1992-93 period. The 
primary care, psychiatry, medical specialties, and RAP 
categories experienced stable average caseloads between 
1993 and 1994. Of these groups, only psychiatry appears 
to have experienced 3 continuous years of stable caseload; 
the others may have seen their caseload growth slow 
compared to the period 1992-93. Allowed charges per 
physician was also examined. Four of the major specialty 
groups' mean allowed charges grew between 7 percent 
and 14 percent. These were LLPs (7 percent), medical 
specialties (8 percent), surgeons (11 percent), and 
psychiatry (14 percent). For the remaining two categories, 
primary care physicians and RAPs, the average allowed 
charges were statistically stable. In comparison to these 
results, findings for the specialty groups in 1992-93 
showed that only one group, medical specialties, had a 
statistically significant gain in average allowed charges. 

Indicators for both caseload and allowed charges continue 
to suggest that access to physician services has not 
deteriorated following introduction of the MFS. 
Physicians' willingness to see Medicare patients, as 
revealed in caseload movements, does not appear to have 
lessened, in view of the stability or improvement in 
caseload measures. The 1993-94 gains in revenues for 
Medicare physicians may be taken to indicate that 
Medicare's economic importance to the physician is 
probably not waning. 

IM-056 Non-Response Bias in the Medicare 
Beneficiary Health Status Registry 

Funding: Intramural 

HCFA Project Thomas W. Reilly, Ph.D. 
Director: Division of Health Information and 

Outcomes 

Description: The Health Care Financing Administration 
is anticipating implementation of a survey to measure the 
health status of Medicare beneficiaries, called the 
Medicare Beneficiary Health Status Registry (Registry). 
It is important to understand differences between 
respondents and non-respondents in such a survey. Using 
Medicare claims and enrollment data, this project will 
compare respondents and non-respondents to the recently 
completed pilot test of the Registry. The study will 
examine factors such as patterns and types of 
hospitalization, ambulatory-care service use, enrollment 
in managed-care plans, and the like. The analysis will 
identify potential non-response bias that might be 
expected in the full Registry. 

Status: The study is in the design phase. 



IM-043 Physician Behavioral Response to Fee Changes 

Funding: Intramural 

HCFA Project Ann Meadow, Sc.D., Jesse Levy, Ph.D., 

and Edgar A. Peden, Ph.D. 
Directors: Division of Payment Systems 

Description: Using physician-level claims data, this 
project will investigate Medicare physician behavior in 
the face of fee changes, primarily those implemented 
under the Medicare fee schedule. Dependent variables 
will include the physician's supply of selected categories 
of services, physician caseload, and Medicare 
participating physician/assignment rates. The dependent 
variables of interest concern services provided to 
Medicare beneficiaries, but the study will control for 
several important influences on physicians' practice, 
including private-insurance fees for physician services 
and beneficiaries' demand for care. 

Status:Creation of the proxy measures of private- 
insurance fees for 1989-93 is near completion. The 
measures comprise annual average fees for each physician 
service at both the metropolitan statistical area and State 
level. After data editing, the fee averages were computed 
for each procedure code and procedure code component 
(technical verses professional component). 

IM-064 Prescription Drug Utilization 
and Expenditures in Medicare 



Funding: 
HCFA Project 
Director: 



Intramural 

Kathleen Gondek, Ph.D. 

Division of Payment Systems 



Description: The objective of this study is to describe the 
utilization and expenditures for prescription drugs in 
Medicare by age, race, and gender. The primary source of 
data for this study is the Medicare Current Beneficiary 
Survey. The utilization will be analyzed by the 
American Hospital Formulary System's drug 
classification scheme. Information on self-reported health 
status, insurance coverage, and other health services 
utilization will be addressed. 

Status: The analysis is in the developmental stage. 

IM-045 Prostate Cancer Care and Outcomes 
Among Medicare Beneficiaries 

Funding: Intramural 

HCFA Project Grace L. Lu-Yao, Ph.D. 
Director: Division of Health Information and 

Outcomes 



Theme 1 : Monitoring and Evaluating Health System Performance 



33 



Description: The objectives of this project include: 

• Describing the survival patterns following different 
initial cancer therapies in men diagnosed with clinically 
localized prostate cancer. 

• Evaluating the patterns of prostate cancer screening, 
treatment, and outcomes in recent years. 

The first component of the project was based on 59,876 
patients identified from the Surveillance Epidemiology, 
and End Results (SEER) population-based cancer 
registries. Disease specific and overall survival was 
evaluated by both an intention-to-treat (ITT) and 
treatment-received (TR) approach. While the ITT and TR 
analyses yielded similar results for radiation and 
conservative management, the 10-year disease-specific 
survival for prostatectomy was considerably more 
favorable when TR approach was used. The overall and 
cancer grade-specific survivals obtained in this study 
differ significantly from those obtained in prior studies. 
Previous studies which have utilized a treatment-received 
(TR) approach have generally overestimated the benefits 
of radical prostatectomy. Moreover, this study shows that 
grade 3 tumors are highly aggressive irrespective of stages 
and significantly impact survival even at 5 years. This 
observation suggests that the 10-year life-expectancy rule 
for administering aggressive therapies to patients with 
clinically localized prostate cancer may need to be re- 
evaluated for patients with grade 3 disease. 

The second component of this project was based on 
Medicare hospital and physician claims filed between 
1984 and 1995. This national study shows that the rapid 
increase in the use of radical prostatectomy reached a 
peak in Medicare aged men in 1992, and thereafter a 
sharp decline was observed in men 70 years of age and 
older. Furthermore, we found that short-term outcomes 
(30-day mortality and major complications) following 
radical prostatectomy have improved significantly in 
recent years (1990-94) compared with those published 
previously. 

Status: A manuscript describing the first component of 
the project is now under review. Two additional papers 
describing the trends of radical prostatectomy among 
Medicare beneficiaries and short-term outcomes following 
radical prostatectomy are currently under review. 

IM-05 1 Stage of Cancer at Diagnosis for Medicare 
HMO and Fee-for-Service Enrollees 

Funding: Intramural 

HCFA Project Gerald F. Riley and James D. Lubitz 
Director: Division of Health Information and 

Outcomes 

Description: The study examined stage of cancer at 
diagnosis for aged Medicare enrollees in health 



maintenance organizations (HMOs) and fee-for-service, 
using information from the Surveillance, Epidemiology, 
and End Results program, linked with Medicare 
enrollment files. Twelve cancer sites were investigated, 
and demographics, area of residence, year of diagnosis 
(1985-89), and education at the census tract level were 
controlled. 

HMO enrollees were diagnosed at earlier stages for 
cancers of the female breast, cervix, colon, and for 
melanomas, and at later stages for stomach cancer. There 
were no differences for cancers of the prostate, rectum, 
buccal cavity and pharynx, bladder, uterus, kidney, and 
ovary. HMO effects were strongest in areas with large, 
mature HMOs. The earlier detection of certain cancers 
among HMO enrollees may result from coverage of 
screening services and, perhaps, promotion by HMOs of 
such services. 

Status: The study has been published under the following 
citation: Riley, G. F., Potosky, A. L., Lubitz, J. D., and 
Brown, M. L.: "Stage of Cancer at Diagnosis for Medicare 
HMO and Fee-for-Service Enrollees." American Journal 
of Public Health, Volume 84, pp. 1,598-1,604, 1995. 

IM-046 Study of Access to Durable Medical Equipment 
by Non-Aged Disabled Medicare Beneficiaries 

Funding: Intramural 

HCFA Project William D. Clark 

Director: Division of Aging and Disability 

Description: This project is examining access to durable 
medical equipment (DME), especially wheelchairs, by 
non-aged disabled Medicare beneficiaries to determine 
whether changes in access have resulted from DME 
payment changes in the Medicare program. The study will 
use Medicare data from 1991 through 1995 to assess 
changes in assignment rates, payment denials, and 
supplier characteristics and other variables. 

Status: A project design and data request are being 
prepared for review. Initial discussions with industry and 
advocacy group representatives have been held. 

IM-017 Trends in Access to Health Care Services for 
Selected Segments of the Medicare Population 

Funding: Intramural 

HCFA Project Renee Mentnech 
Director: Division of Delivery Systems and 

Financing 

Description: Trend data on access to health care services 
will be developed for the years prior to, during, and after 
implementation of physician payment reform (PPR). The 
focus will be on vulnerable subgroups of the Medicare 
population such as persons with low income, persons 



34 



Theme 1: Monitoring and Evaluating Health System Performance 



without supplemental medical insurance, and persons 
with acute and chronic conditions. Geographic differences 
also will be examined. These trend data will be derived 
from the National Health Interview Survey (NHIS) 
conducted by the National Center for Health Statistics. 
The years 1984, 1986, 1989, 1990, and 1991 will be used 
to develop pre-PPR baseline data. The years 1992 and 
1993 will be used to develop post-PPR data. 

Status: Descriptive data for 1984, 1986, 1989, 1990, 
1991, 1992, and 1993 have been developed by 
sociodemographic characteristics. Relative standard errors 
have been computed by using a software package that 
takes complex sample designs into account. A multi- 
variate model with 1984, 1986, 1989, 1990, 1991, and 
1992 data has been developed to assess the impact of 
specific factors on use of physician services. Analysis of 
these data was incorporated into the 1993, 1994, and 
1995 Reports to Congress on Access to Physician 
Services. An article, "An Analysis of Utilization and 
Access from the NHIS: 1984-1992," was published in the 
Health Care Financing Review, Volume 17, Number 2, 
Winter 1995. 

IM-025 Upper Gastrointestinal Endoscopy in the 
United States: Geographic Variation in 
Practice Patterns 

Funding: Intramural 

HCFA Project Renee Mentnech 
Director: Division of Delivery Systems and 

Financing 

Description: Upper esophagogastroduodenoscopy (EGD) 
is a commonly performed procedure with well-defined 
indications. However, little is known about the practice 
patterns for this procedure, specifically the number 
performed. The purpose of this study is to examine 
variations in the use of endoscopy on Medicare patients in 
the United States and how variations in endoscopy rates 
relate to variations in the rates of hospitalizations for 



gastrointestinal disorders. Use of upper gastrointestinal 
X-rays will also be incorporated into the analysis to 
determine whether these two services are being used as 
substitutes for each other. 

Status: All aged Medicare patients who underwent EGD 
and upper gastrointestinal X-ray in 1993 were identified 
by using Current Procedural Terminology codes. Rates of 
endoscopy and upper gastrointestinal X-ray for the top 
50 metropolitan statistical areas by gender and race are 
being developed. Hospitalization rates for diagnoses for 
which an EGD is indicated are also being compared. The 
supply of gastroenterology training programs for 
physicians is being examined to determine the effect on 
utilization. A paper is being prepared. 

IM-065 Use of Mental Health Services by 
Medicare Enrollees 

Funding: Intramural 

HCFA Project Carlos Cano, Jay Bae, Joan Warren, 

and James D. Lubitz 
Director: Division of Health Information and 

Outcomes 

Description: Mental health service use is of policy interest 
because of changing attitudes among the elderly on 
mental health services, because of the liberalization of 
Medicare coverage for outpatient mental health service, 
because of the growth in partial hospitalization, and 
because of the increasing role of managed care in mental 
health delivery to the non-Medicare population. This 
study will examine the use and cost of Medicare-covered 
mental health services. It will analyze use by diagnosis, 
type of service (e.g. inpatient, outpatient, etc.), and by 
beneficiary characteristics such as age and whether 
entitled due to old age or disability. 

Status: Work has begun on a study of inpatient hospital 
use for psychiatric diagnoses. After this is completed, use 
in physician and outpatient settings will be examined. 



Theme 1 : Monitoring and Evaluating Health System Performance 



35 



Theme 2: Improving Health Care Financing and Delivery 
Mechanisms: Current Programs and New Models 



Extramural 

92-022 Actuarial Methods for Improving Health 
Care Financing Administration Payment to Risk 
Health Maintenance Organizations 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



17-C-90033/3 
February 1992-April 1996 
$449,510 
Cooperative Agreement 

Charles William Wrightson 
Actuarial Research Corporation 
6928 Little River Turnpike, Suite E 
Annandale, VA 22003 
Cynthia G. Tudor, Ph.D. 
Division of Delivery Systems and 
Financing 



Description: This project assessed four alternatives to the 
adjusted average per capita cost (AAPCC) method for 
paying Medicare health maintenance organizations 
(HMOs). They are: 

• Partial capitation: Some services are paid on a 
prospective capitation basis, and others are paid 
retrospectively on a cost basis. 

• Reinsurance with Medicare as the reinsurer. 

• Prospective experience rating in which a prospective 
payment will be made on the basis of past experience. 

• Select and ultimate rates: This method takes into 
account initial favorable selection with an adjustment 
for regression to the mean over time. 

Status: Analysis is completed. The final report suggests 
that: 

• Although the AAPCC explains less than 1 percent of 
the variance in Medicare costs at the individual level, it 
performs better at the group level. However, it does not 
perform as well as some of the other payment methods 
investigated in this project. 

• Partial capitation models were quite successful in 
limiting the amount of financial risk that must be borne 
by health plans, especially for plans with smaller 
Medicare enrollments. Partial capitation with risk 
corridors was especially promising. 

• Reinsurance models were effective in providing plans 
with protection against high-risk cases and catastrophic 
expenses. 



• The analysis of select and ultimate rates indicated that 
rate adjustments for the initial enrollment in an HMO 
can help to mitigate, but not completely account for, the 
adverse consequences of severe selection effects. 

• While experience rating is the principal method used by 
private insurers to set premiums for employer- 
sponsored groups, the analysis indicated that this 
payment method was comparable to the AAPCC. The 
relatively low level of accuracy resulted from the 
difficulty in predicting deaths, changes in groups, and 
the frequency and severity of high-cost cases in the 
Medicare population. 

94-107 Alternative Health Risk Adjusters for the 
Medicare Risk Program 



Project No.: 

Period: 

Funding: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



17-C-90366/3 

September 1994-September 1997 

$501,581 

Sheldon Retchin, M.D. 

Virginia Commonwealth University 

P. O Box 980568 

Richmond, VA 23298-0568 

Cynthia G. Tudor, Ph.D. 

Division of Delivery Systems and 

Financing 



Description: The goal of this project is to develop an 
implementable risk adjuster that is based on a history of 
cancer, heart disease or stroke, and severity of illness; the 
length of time since the last hospital stay; and 
comorbidities. The predictive power from using history of 
serious illness will be compared to the predictive power of 
two existing risk adjusters — the diagnostic-cost-group and 
ambulatory-care-group models. Both predictive accuracy 
and operational features will be compared. The study is 
intended to yield information on the extent to which the 
health risk adjusters are likely to eliminate over- or 
underpayment in the Medicare risk program under 
various assumptions about biased selection in health 
maintenance organizations. The ultimate objective is to 
revise the risk-adjustment procedures used in the 
Medicare risk program. 

Status: This project defines rate cells for beneficiaries 
based on whether they were hospitalized at some time in 
the previous 4 years for cancer, heart disease, or stroke, 
with payment rates varying by the diagnosis and the 
length of time since the most recent (or first) 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



37 



hospitalization. Preliminary estimates of rate cells for 
beneficiaries with one of these conditions range from a 
low of 1 .30 times the overall mean cost (for women with 
breast cancer) to a high of 5.1 times the overall mean cost 
(for leukemia cases), with most of the rates in the 1.5 to 
2.5 range. This contrasts with the adjusted average per 
capita cost (AAPCC) methodology, which has a 
maximum rate factor of 2.5. Correspondingly, the relative 
rates for people without one of these diseases decreased 
markedly relative to the current AAPCC (by about 20 
percent). The new rate cells would include about 
13 percent of the fee-for-service population. 

Considerable work to refine the adjustor will be 
undertaken in order to deal with individuals with 
comorbidities, including additional non-gameable disease 
associated with high future costs, and incorporate a 
retrospective adjuster for certain diseases into the new 
prospective rate structure. The study will then compare 
the relative performance of this risk adjustor to that of 
alternatives. Additional findings are expected in 
early 1997. 

94-046 Analysis of Post-Acute Care and 
Therapy Services Using the Health Care 
Financing Administration Episode Database 



94-092 Assessing the Compatibility of an All-Payer 
Ratesetting System and Managed Competition: 
The Maryland Experience 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



500-89-0047/46 
August 1994-April 1995 
$ 138,300 
Contract 



David Kennell 

Lewin/VHI, Inc. 

(See page 17) 
HCFA Project Carolyn Rimes 
Officer: Division of Aging and Disability 

Description: This two-part study uses the Health Care 
Financing Administration Episode Database to: 

• Update earlier research on post-hospital care and 
rehabilitation following hospital admissions with more 
recent data. 

• Examine trends in use over time by comparing the 1992 
findings to several Rand analyses and a Lewin/VHI 
analysis on therapy services conducted for the 
American Association for Retired Persons. 

• Analyze the use of rehabilitation/therapy services across 
settings. 

• Contribute to the discussion of policy and payment 
implications of increased use of post-acute services. 

Status: Tabulations on rehabilitation are under way. The 
post-acute analysis is expected in January 1997. 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-90372/1 

September 1994-September 1995 

$ 153,763 

Cooperative Agreement 

Stanley Wallack, Ph.D. 

Brandeis University 

Heller Graduate School 

Institute for Health Policy 

415 South Street 

P.O. Box 91 10 

Waltham, MA 02254-9110 

Brigid Goody, Sc.D. 

Division of Delivery Systems and 

Financing 



Description: The purpose of this project is to analyze the 
effect of two features of the Maryland all-payer system on 
hospital costs and utilization rates of health maintenance 
organizations (HMOs) from 1986-92. First, rates are set 
for individual services, and reimbursement is provided for 
services actually rendered. Second, different rates are set 
for different hospitals. The project examines the 
hypothesis that Maryland HMOs lower expenditures by 
limiting services and choosing less expensive hospitals. 

Status: A final report, "Assessing the Compatibility of 
All-Payer Systems and Managed Competition: The 
Maryland Experience," accession number PB96- 162284, 
is available from the National Technical Information 
Service. The report analyzes the difference between HMO 
and non-HMO hospital cost per discharge and average 
length of stay (ALOS). Principal findings include: 

• Unadjusted savings in HMO cost per discharge and 
ALOS is 25 percent. 

• Less severe HMO admissions as measured by diagnosis- 
related groups account for 60 percent of the HMO 
savings in cost per discharge. 

• HMO case-mix-adjusted ALOS is 13 percent shorter 
than non-HMO ALOS. 

• Additional HMO savings resulted from their choice of 
hospitals. 

94-002 Assessment and Redesign of Medicare 
Fee Schedule Areas (Localities) 



500-92-0020DO09 

July 1994-October 1995 

$ 125,882 

Delivery Order in Master Contract 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: Gregory C. Pope, Ph.D. 



3H 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



Awardee: Health Economics Research, Inc. 

(See page 193) 
HCFA Project Benson L. Dutton 
Officer: Division of Payment Systems 

Description: This delivery order reassessed the 210 (as of 
January 1995) Medicare Part B pricing locality areas and 
made recommendations on the feasibility of using some 
other geographic configuration such as States, 
metropolitan statistical areas (MS As), or county- 
groupings as Medicare fee schedule areas (MFSAs). 
Currently, no standard geographic definition of a 
Medicare payment locality exists. For 22 States, the entire 
State is a single payment locality. In the remaining 
28 States, there are multiple localities, ranging from 32 in 
Texas to 2 localities in Idaho. Massachusetts. Michigan, 
and Mississippi. Localities were established by Medicare 
carriers (fiscal agents) to reflect local differences in 
medical practice and economic conditions. Once 
established, localities could not be changed without just 
cause. Consequently, with the exception of consolidations 
to a State locality. Medicare physician payment 
boundaries have remained stable since 1966. The Health 
Care Financing Administration (HCFA), in reassessing 
the current multistate MFSAs, feels that the distinctions 
that dictated the original locality definitions are no longer 
meaningful. 

Status: This project has been completed. Four options 
were evaluated as alternatives to the current MFSAs based 
on the percentage differences between the 1996 
geographic adjustment factor (GAF) and that for each 
option using a range of thresholds to simulate changes in 
the GAF as compared to current locality configurations. 
Option 1 is based on MFSAs as the building block. 
Option 2 is based on MSAs, Option 3 is based on 
metropolitan area population classes within States, and 
Option 4 uses metropolitan population classes to define 
five areas nationally. The study also addresses the 
problem of sub-county localities. For payments beginning 
January 1, 1997, HCFA proposed the county be the 
minimum geographic unit for constructing payment 
localities and adoption of Option 1. 5-percent threshold, 
a variation of Option 1. resulting in 87 MFSAs. A final 
report in three volumes has been received. The final 
report, "Assessment and Redesign of Medicare Fee 
Schedule Areas (Localities)," Vol. I: Text, Vol. II: 
Appendix Tables, and Vol. Ill: Maps, are available from 
the National Technical Information Service (XTIS). The 
NTIS accession numbers for ordering copies of the final 
report are: Vol. I. PB96-1 18815; Vol. II. PB96-1 18823; 
and Vol. III. PB96-1 18187. 

94-065 Bundle Payment for Physician and 
Hospital Services Using Telemedicine Services 

Project No.: 95-C-90384/3 



Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



July 1994-July 1997 

S 1.568.476 
Grant 

William W. Reeves 

West Virginia University 

Research Corporation 

Office of Sponsored Programs 

P. 0. Box 6845 

Morgantown, WV 26506-6845 

William L. England, Ph.D., J.D. 

Division of Health Information and 

Outcomes 



Description: This project will investigate whether 
changing the current Medicare payment policy for 
telemedicine enhances patients' access to care and 
improves the quality of care delivered in rural 
communities, while limiting the growth of health care 
spending. West Virginia University's Mountaineer Doctor 
Television (MDTV) program currently links seven rural 
spoke sites (Davis Memorial Hospital in Elkins, Grant 
Memorial Hospital in Petersburg, Boone Memorial 
Hospital in Madison. St. Joe's Hospital in Buckhannon. 
William Sharpe Hospital in Weston, Roane General 
Hospital in Spencer, and Braxton County Memorial 
Hospital in Gassaway. with two hub sites, the Robert C. 
Byrd West (Virginia University) Health Sciences Center 
in Morgantown and Charleston Area Medical Center in 
Charleston. While hospital and administrative expenses 
are covered under the grant, payment for actual delivery 
of medical care requires a demonstration waiver of 
Medicare payment regulations. The major objective of the 
project is to develop a payment system for inpatient 
telemedicine consultations. Related objectives include 
development of a coding system for inpatient telemedicine 
consultations, increasing the number of inpatient 
telemedicine consultations, and reducing interhospital 
transfers by 50 percent. The effect of the payment system 
on the number and types of charges generated by 
Medicare patients at rural MDTV sites will be evaluated. 
The cost effectiveness and feasibility of telemedicine 
follow-up for patients returned from the referral center to 
the rural hospitals for the remainder of their 
hospitalization will be evaluated. 

Status: Developmental work setting up the sites has been 
completed. A Medicare waiver to permit payment to 
providers participating in the project was recently 
approved. No data is available at this time. 

92-030 Bundling Physician Services 

Project No.: 500-89-0050 

Period: March 1992-August 1996 

Funding: 5 354,418 

Award: Contract 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



Principal 

Investigator: A. James Lee. Ph.D. 

Awardee: Health Economics Research, Inc. 

300 Fifth Avenue, 6th Floor 

Waltham, MA 02154 
HCFA Project Teresa L. DeCaro 
Officer: Division of Payment Systems 

Description: The purpose of this project is to develop and 
evaluate innovative alternatives to packaging ancillary 
sen ices with physician office-based visits. It involves five 
discrete tasks including assessing the reliability of 
diagnostic coding and unique physician identification 
numbers (UPINs) in the 1992 Part B National Claims 
History data; developing a criteria paper to guide the 
development and evaluation of alternative bundling 
strategies; conducting descriptive analyses of various 
ancillary bundles; exploring the application of ambulatory 
patient group (APG) assignment and weighing algorithms 
to physician services provided in an office setting; and 
simulating redistributive impacts of various bundling 



Status: Three early reports include: "An Exploratory 
Investigation of UPIN and Diagnostic Reporting in the 
National Claims History;" "Descriptive Analysis of 
Ancillary Service Bundles;" and "Criteria Paper: Issues in 
Visit-Based Bundling." The criteria paper is available 
from the National Technical Information Service, 
accession number PB93-184158. It explores equity- 
efficiency tradeoffs using various examples of bundles 
that conceptually make up a packaging continuum. 
Design issues are discussed, and evaluation criteria are 
developed, including cost reduction potential, 
redistributive consequences, potential for inappropriate 
responses, and administrative feasibility. It presents four 
ancillary bundling models, all targeting high-volume, 
low-cost ancillaries. These models were built and 
analyzed using a 5-percent sample of 1992 national 
claims history data. Ancillaries were attributed to visits 
using a hierarchical matching algorithm involving UPIN 
numbers, diagnosis codes, and 7-day pre- and post- 
windows. Seventy-seven percent of ancillaries were 
attributed to office visits using these rules. Only one 
model — the common diagnosis model — demonstrated 
significant, practical potential for future payment. In this 
model, diagnosis groups are formed using clinical input. 
Visits are classified according to CPT-4 definitions and 
then subdivided by diagnosis group using the diagnosis on 
the visit claim. Ancillaries are then attributed to each visit 
according to the hierarchical method. For each subdivided 
visit type, the average utilization of high-volume, low-cost 
ancillaries is measured and transposed into an adjustment 
weight that increases the visit relative value unit. Finally, 
bundled payment of ancillaries into visits using the 
adjustment weights is simulated to measure the 



distribution impacts by geographic region and physician 
specialty. Only five specialties, accounting for 5 percent 
of visits, gain 2 percent or more. Two specialties, 
accounting for 1 percent of visits, lose 2 percent or more. 
Distributional impacts are significantly larger across 
geographic regions. 

Administrative issues of visit-based ancillary bundling are 
explored, as are the necessary analytic steps to complete 
the development of this payment model. The exploration 
of APG classification and bundling scheme using 
physician office claims is the first step toward evaluating 
APGs as a method for bundling physicians' office 
ancillary services. A report is pending that describes the 
descriptive and explanatory findings under this task. 

94-091 Business Health Care Purchasing Coalitions 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-90329/9 
September 1994-July 1996 
$ 198,667 
Cooperative Agreement 

Peter Jacobson 

Rand Corporation 

1700 Main Street 

P.O. Box 2138 

Santa Monica, CA 90407-2138 

Brigid Goody, Sc.D. 

Division of Delivery Systems and 

Financing 



Description: The purpose of this project is to assess the 
success of business health care purchasing alliances in 
reducing health care costs and in expanding access to 
previously uninsured employees. Case studies of eight 
coalitions in six metropolitan areas were conducted to 
answer the following research questions: 

• How do business health care purchasing coalitions form 
and operate? 

• How does the health care market change in response to 
coalition activity? 

• What are the policy implications of coalition formation 
and operations? 

Status: The final report, "The Operation of Business 
Health Care Purchasing Coalitions," presents findings 
from the case studies. Although the evidence is 
inconclusive on the ability of coalitions to reduce health 
care costs or to restructure the health care market, the 
study suggests that coalitions have stimulated price 
reductions in the marketplace for small and mid-size 
firms. Providers and insurers are willing to negotiate 
premium reductions with coalitions. Copies of the report 
(PM-554-1-HCFA) are available from Rand, 1700 Main 
Street, Post Office Box 2138, Santa Monica, California 
90407-2138. 



40 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



96-057 Case-Mix Adjustment for a National 
Home Health Prospective Payment System 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0003/0002 

August 1996-January 1999 

S L588.573 

Long-Term Care Task Order 

Henry Goldberg 
Abt Associates, Inc. 
55 Wheeler Street 
Cambridge, MA 02138 
Elizabeth Mauser, Ph.D. 
Division of Aging and Disability 



Description: The primary focus of this study is to 
understand the variation that currently exists in terms of 
home health resource patterns and to use this information 
for the development of a case-mix adjustment system for a 
national home health prospective payment system. In this 
study, the Outcome and Assessment Information Set 
(OASIS) which has been developed for outcome-based 
quality assurance and improvement for Medicare home 
health agencies will be examined to see whether items 
included in this instrument will be useful for case-mix 
adjustment. Detailed information, including information 
on resource utilization and items needed for case-mix 
adjustment, will be collected from 60 to 90 agencies. 

Status: This project is currently in its design phase. 

93-089 Case Studies of Medicaid Estate Planning 

(Formerly, Long-Term Care Studies (Section 207)) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



500-89-0047/39 

April 1993-December 1994 

S 200,000 

Contract 



David Kennell 

Lewin/VHI, Inc. 

(See page 17) 
HCFA Project Carolyn Rimes 
Officer: Division of Aging and Disability 

Description: These case studies provide in-depth 
descriptive analyses of State policy responses to Medicaid 
estate planning, including the effectiveness of estate 
recovery programs. In addition, a methodology for 
conducting quantitative empirical studies that measure the 
extent of Medicaid estate planning activity and the 
relative cost-effectiveness of alternative State policy 
responses is presented. The data used were obtained from 
Medicaid eligibility offices in California. Connecticut, 
Florida, and New York. This project was completed 
by SysteMetrics MedStat. under subcontract to 
Lewin VHL Inc. 



Status: The report has been received and is under review. 

92-098 Catastrophic Costs of Long-Term Care 
for Elderly Americans (Formerly, Long-Term Care 
Studies (Section 207)) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



500-89-0047/12 

December 1991— November 1995 

S 50,000 

Contract 



David Kennell 

Lewin/VHI, Inc. 

(See page 17) 
HCFA Project Carolyn Rimes 
Officer: Division of Aging and Disability 

Description: This study employs the Brookings/ 
Intermediate Care Facility Long-Term-Care Financing 
Model to examine both current and future financial 
burdens associated with long-term-care costs. This 
chapter focuses on the financial burden that out of pocket 
expenditures will have in the next 25 years, assuming that 
there are no changes in public or private financing. The 
results of these long-term-care spending projections 
included both nursing home and home health care. 
Catastrophic nursing home spending patterns of selected 
elderly groups, by age, gender, income financial status, 
length of stay and discharge status are also described. 

Status: Findings from this study have been published in 
conference proceedings from the Brookings Institute. The 
publication, Persons with Disabilities, is available from 
the Brookings Institute. 

94-008 Collect Malpractice Insurance 
Premium Rate Information 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-94-0039 
July 1994-June 1997 
$ 347,892 
Contract 

Karen Reilly, Sc.D. 

Allied Technology Group, Inc. 

1803 Research Boulevard, Suite 601 

Rockville, MD 20850 

Benson L. Dutton 

Division of Payment Systems 



Description: This study surveys State insurance 
commissioners, physician-owned malpractice insurers, 
physician associations, cooperatives, and physician joint 
underwriting associations. Premium rate data will be 
obtained from State insurance departments. These data 
will be used by the Health Care Financing Administration 
(HCFA) staff and outside contractors to update the 
malpractice component of the Medicare Economic Index 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



41 



(MED and to refine the malpractice component of the 
geographic practice cost index (GPCI) for the Medicare 
fee schedule (MFS). By law, HCFA is required to compute 
the annual rate of increase in malpractice insurance costs 
for use in the MEI and to periodically review and update 
the GPCI. Section 1848(e) of the Omnibus Budget 
Reconciliation Act (OBRA) of 1989 (Public Law 101-239) 
and section 41 18 of OBRA 1990 (Public Law 101-508) 
require the Secretary of the Department of Health and 
Human Services to develop and update geographic 
adjustment factors for existing payment localities used in 
calculating the MFS. Project tasks also include developing 
methods for collecting representative premium data for 
the national MEI estimates and the GPCI market areas; 
investigating possible expansion to the survey; 
determining the existence, composition, and authority of 
any State patient compensation funds and joint 
underwriting associations; and linking the 1993-95 
premium data collected under this survey with the 1989- 
92 data collected previously. 

Status: Tasks completed in the first 2 years include: 

• Interviewing State insurance commissioners' staff to 
identify physician medical liability insurance companies 
in the State. 

• Collecting $1 million/$3 million malpractice premium 
rates for policies for 1993-95 from State insurance 
commissioners' office files, if available, and otherwise, 
through contacting key insurance company personnel 
named by the State insurance office. 

• Identifying any sub-State coverage and pricing areas. 

For the third year, ATG will continue their collection 
tasks begun in the first 2 years. In addition they will 
produce a options paper on alternatives for weighting data 
within GPCI areas and across GPCI areas to obtain a 
natural MEI and link 1993-95 premium data collected 
under this survey with the 1989-92 data collected by the 
Urban Institute into a homogeneous file. 

92-072 Community Nursing Organization 
Demonstration: Living at Home/Block 
Nurse Program 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Avvardee: 



HCFA Project 

Officer: 



500-92-0052 

September 1992-December 1997 

S 193,938 

Contract 

Linda Robertson 

Living at Home/Block Nurse Program 

Ivy League Place, Suite 225 

475 Cleveland Avenue North 

St. Paul, MN 55104 

Melissa Hulbert, MPS 

Division of Aging and Disability 



Mandate: Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 

Description: The purpose of the Community Nursing 
Organization (CNO) demonstration is to develop and 
evaluate a nurse-case-managed health-care delivery 
system that provides Medicare-covered home health 
services, ambulatory care services, and durable medical 
equipment to eligible beneficiaries. Section 4079 of Public 
Law 100-203 directed the Secretary of the Department of 
Health and Human Services to conduct this demonstration 
at four or more sites. The authorizing legislation 
identified a package of mandatory services that each CNO 
has to provide. It also required that the demonstration 
have a capitated payment method modeled after the 
average adjusted per capita cost payment used with health 
maintenance organizations. Another provision of the 
legislation stipulated that an alternative capitation 
formula be implemented in at least one of the four sites. 
The participating organizations assume full financial risk 
for the demonstration's mandatory service package. In 
addition to these services, the Living at Home/Block 
Nurse Program provides optional services such as 
homemaker/home health aide services and respite care. 
The project's evaluation will examine the feasibility and 
viability of a capitated nurse-coordinated service model. 

Status: On September 30, 1992, the Living at Home/Block 
Nurse Program was awarded one of four contracts to 
conduct the CNO demonstration. During the project's 
developmental year, the Living at Home/Block Nurse 
Program established its organizational protocol, 
marketing and enrollment plan, service delivery system, 
and data collection plan for implementation of the CNO 
demonstration. The 3 -year operational phase of the 
demonstration began in January 1994. A 1-year extension 
of the demonstration and evaluation is pending. Abt 
Associates was selected to evaluate the project and to 
provide technical assistance to the four CNO sites. Abt 
Associates also was awarded the external quality 
assurance contract. 

96-038 Comparison of Concurrent DCG Models and 
Partial Capitation as Payment Alternatives for 
Managed-Care Organizations 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



HCFA-96-0558 
September 1996-January 
$ 49,000 
Purchase Order 



997 



Gregory C. Pope 

Health Economics Research 

300 Fifth Ave, 6th Floor 

Waltham, MA 02154 

Melvin J. Ingber, Ph.D. 

Division of Delivery Systems and 

Financing 



42 



heme 2: Improving Health Care Financing and Delivery Mechanisms 



Description: This project will simulate and compare 
payments that would be made for a capitated Medicare 
population under alternative methods. The first method to 
be simulated is payment using a concurrent year risk- 
adjuster model from the hierarchical coexisting condition 
(HCC) models developed under identifier 93-045. The 
second method is a partial capitation system in which 
Part B services would be capitated; Part A services would 
be paid on a weighted average of the capitated payment 
and the fee-for-service value of services provided. 
Variants of these basic methods will be simulated and 
compared. 

Status: The project is in the initial phases. 

94-108 Congestive Heart Failure Outreach Project 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-P-90365/5 

September 1 994-September 1997 

$ 830,395 

Grant 

Joseph P. Malone, M.D. 

Miami Valley Hospital 

One Wyoming Street 

Dayton, OH 45409 

Renee Mentnech 

Division of Delivery Systems and 

Financing 



Description: Miami Valley Hospital is a large hospital in 
Ohio with 811 beds. This hospital, in cooperation with 
Wright State University-Miami Valley School of Nursing, 
will analyze whether post-hospital education and 
intensive case management can reduce rehospitalization 
rates for congestive heart failure (CHF) patients. Patients 
admitted to the hospital with a CHF diagnosis and 
discharged to a home will be assigned to case- 
management follow-up or to standard post-hospital care. 

Status: Recruitment of patients began in January 1995. 
The data systems have been tested and are fully 
operational. Through June 2, 1996, 670 patients were 
identified as potential subjects, that is, these patients had 
an impression of CHF on admission. Of these, 179 agreed 
to participate and met the eligibility criteria; 138 refused; 
and 353 were not eligible (85 were readmissions; 80 were 
residents of extended care facilities; 55 were already in 
long-term visiting nurses programs; 14 were on artificial 
kidney units; 28 had other comorbidities, such as cancer; 
28 resided outside the Zip code area; 15 died while 
hospitalized; 1 1 were discharged prior to recruitment; and 
37 were not eligible for a variety of other reasons). 



Of the 179 patients who agreed to participate, 50 were 
discharged with traditional skilled home care and could 
not be randomized into the case management or control 
group until after being released from the home care 
program. Only 26 of these 50 patients have been released 
from the home care program and Randomly assigned into 
a treatment or control group. Preliminary results show 
that the group discharged with traditional home care is 
more severely ill than those discharged without home care 
(mean New York Heart Association (NYHA) 
classification of 2.92 versus 2.29, p<.0001). Patient 
recruitment is continuing. 

93-091 Consumer Protection and Private 
Long-Term-Care Insurance: Key Issues for 
Private Long-Term-Care Insurance 

(Formerly, Long-Term Care Studies (Section 207)) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



500-89-0047/16 
December 1 992— December 
$ 130,000 
Contract 



994 



David Kennell 

Lewin/VHI, Inc. 

(Seepage 17) 
HCFA Project Carolyn Rimes 
Officer: Division of Aging and Disability 

Description: This study consists of a two-part analysis. 
The first is a policy-oriented synthesis of research 
conducted to date on long-term-care (LTC) insurance. 
The purpose of this synthesis is to serve as a baseline of 
understanding for policymakers and to identify relevant 
issues at which future research should be directed. The 
second part focuses on regulatory issues. This part 
contains case studies of Arizona, California, Florida, 
Indiana, North Dakota, New York, Oregon, South 
Carolina, Texas, and Wisconsin, which have passed 
legislation to regulate private LTC insurance, and 
summarizes how insurance companies have responded to 
this regulation. This project was carried out jointly by 
Lewin/VHI and the Brookings Institution. 

Status: The policy-oriented synthesis has been completed. 
This synthesis discusses the growth of the LTC insurance 
market from fewer than 50,000 policies in 1984 to nearly 
3 million sold in 1992. Although this growth is 
significant, the market penetration is less than expected; 
approximately 5 percent of the elderly have LTC 
insurance, while 70 percent purchase Medigap policies. 
The study reviews potential reasons for limited market 
penetration, including consumer confusion, barriers to 
coverage, marketing and sales abuses, concern over 
product value, and regulation. 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



43 



92-045 Cost-Containment Measures for 
Physician and Other Services 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



500-89-0052 

August 1992-November 1993 

S 71,957 

Contract 

Suzanne Felt-Lisk 
Mathematica Policy Research, Inc. 
600 Maryland Avenue, SW., Suite 550 
Washington, DC 20024-2512 
Herbert A. Silverman, Ph.D. 
Division of Payment Systems 

Omnibus Budget Reconciliation Act 
of 1990 (Public Law 101-508) 



Description: The awardee conducted a survey of all State 
Medicaid agencies concerning their utilization 
management activities during 1993, including ambulatory 
surgery, pre-admission testing, same-day surgery, primary 
care or other case management, pre-admission 
certification, lock-in, rebundling, and second surgical 
opinion. The objective of the survey was to determine 
which States have which types of programs; the 
characteristics of the programs, including target 
populations, subject procedures, and payment issues; and 
the evidence and opinions States have as to the effects of 
each of the programs on access to necessary care, quality 
of care, and costs of care. 

Status: Mathematica submitted a report of its survey 
findings and a review of the literature. A Report to 
Congress was released on February 28, 1996. In 
accordance with the congressional mandate, the focus of 
the report was on the use and prevalence of ambulatory 
surgery, same-day surgery, and pre-admission testing 
policies. 

In 1993, 32 States had ambulatory surgery policies, 
15 had same-day surgery policies, and 1 1 had pre- 
admission testing policies. Despite the relative paucity of 
pre-admission testing policies, it was found that this is 
general medical practice and such policies would be 
redundant. All three programs reduce program costs by 
obviating the need for or reducing the length of an 
inpatient admission. They do so by shifting the locus of 
services to outpatient settings when technically and 
medically feasible. Such a shift of site eliminates or 
reduces inpatient room and board charges. The report 
recommended against the enactment of legislation or the 
issuance of regulations requiring that State Medicaid 
agencies adopt policies for ambulatory surgery, pre- 
admission testing, or same-day surgery. 



The detailed findings of the survey have been reported in 
the Health Care Financing Review. Citation: Buck, J. A. 
and Silverman, H. A.: "Use of Utilization Management 
Methods in State Medicaid Programs." Summer 1996. 

95-014 Data Collection and Analysis for Generating 
Procedure Specific Practice Expense Estimates 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



500-95-0009 

March 1995-December 1996 

$ 2,959,150 

Contract 

James Highland, Ph.D. 
Abt Associates, Inc. 
55 Wheeler Street 
Cambridge, MA 02138 
Jesse M. Levy, Ph.D. 
Division of Payment Systems 

1994 Amendments to the Social Security 
Act (Public Law 103-105, Section 221) 



Description: Under the original mandating legislation for 
the Medicare fee schedule (MFS), the relative values for 
practice expenses are based on historical charges. This 
method has been widely criticized for not being based on 
the costs of providing services. This study will collect data 
that will be used to derive resource-based relative values 
for practice expenses. Panels of clinicians will be used to 
enumerate practice inputs (e.g., non-physician labor, 
equipment, and supplies) for physician services that are 
paid under the MFS. Secondary price and wage 
information will be used to convert these inputs into 
direct cost estimates for physician services. A survey of 
practice costs was also to be performed as part of this 
study. 

Status: The panels of physicians have enumerated inputs 
for the overwhelming majority of services performed 
under the Medicare fee schedule. Because of a poor 
response rate in a large pilot test, the practice expense 
survey was terminated. 

94-097 Demonstration of Managed Care Under 
Medicare Using Volume Performance Standards 
Organizations 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 



95-C-90388/1 

September 1994-March 1998 

$ 1,206,693 

Cooperative Agreement 

Christopher P. Tompkins, Ph.D. 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



Awardee: Brandeis University 

Heller Graduate School 

Institute for Health Policy 

415 South Street 

P. O. Box 91 10 

Waltham, MA 02254-9110 
HCFA Project Teresa L. DeCaro 
Officer: Division of Payment Systems 

Mandate: Omnibus Budget Reconciliation Act of 

1989 (Public Law 101-239) 

Description: The purpose of this project is to demonstrate 
the physician-group volume-performance standard 
(GVPS) model which creates a partial risk-sharing 
arrangement between participating physician-sponsored 
groups and the Health Care Financing Administration 
(HCFA) under the fee-for-service (FFS) program. To 
participate, the group would have to meet quality and 
other standards, and submit case management and other 
clinical strategies to improve the disease management and 
coordination of care for selected types of high-cost 
patients. Each group would operate under FFS. At the end 
of each year, the group's actual case-mix-adjusted 
performance would be compared to its per capita target, 
based on the group's historical experience, updated by a 
rate-of-growth factor. The difference between the target 
and actual performance would be considered Medicare 
savings. While the target would be based on all Medicare 
reimbursements per unique patient seen (RPUPS) by the 
group, the bonus formula for Medicare savings would be 
constrained by the percent of total services actually 
provided by the group. This percentage is called the 
patient capture ratio (PCR). A second multiplier would be 
a predetermined percent amount of savings that HCFA 
would share. Finally, the total bonus payment would be 
capped. Groups would be provided with profiles of their 
utilization to assist in meeting their targets in a clinically 
cogent manner. The demonstration will include several 
nationally recognized physician group practices. The 
goals of this demonstration include: 

• Testing whether selected physician organizations can 
improve the efficiency and delivery of services to 
Medicare beneficiaries in the fee-for-service sector. 

• Testing and refining reimbursement and incentive 
systems that reward providers for delivering care 
efficiently. 

• Developing new techniques for using information for 
organizational and clinical decisionmaking (profiling) 
to facilitate controlling costs without sacrificing quality 
or access to care. 

• Targeting GVPS models at selected physician group 
practices that could represent "best practices" and 
provide clinical and managerial leadership toward the 
objective of improved efficiency in the fee-for-service 
market. 



• Developing and testing the feasibility of the required 
administrative infrastructure. 

This demonstration follows research and development of 
the GVPS model under two prior studies (99-C-98526/1 
and 17-C-90 129/1). These studies and this demonstration 
respond to legislation enacted along with the 
implementation of the national Medicare volume 
performance standard (MVPS) in the Omnibus Budget 
Reconciliation Act of 1989 (section 6102a). The 
legislation specifies that the Secretary shall implement a 
plan under which qualified physician groups can elect 
annually separate performance standard rates of increase 
other than the national standard established for the year. 

Status: The basic demonstration design is completed. An 
article written by Christopher Tompkins, Stanley 
Wallack, and others, "Bringing Managed Care Incentives 
to Medicare's Fee-for-Service Sector," in the Health Care 
Financing Review, Volume 17, Number 4, Summer issue, 
describes the rationale for GVPS and its incentive 
structure. HCFA is preparing instructions for submitting 
applications that will go out to the ten sites that offered to 
participate under the cooperative agreement. Applications 
will likely be due and go under review in December 1996. 
The demonstration is expected to begin in early 1997, and 
include 3 performance years under GVPS. 

95-012 Derivation of Relative Values for Practice 
Expenses Using Extant Data: HERI 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 

HCFA Project 
Officer: 



500-92-0020DO10 

April 1995-March 1996 

$ 82,796 

Delivery Order in Master Contract 



Gregory C. Pope 

Health Economics Research, 

(See page 193) 

Jesse M. Levy, Ph.D. 

Division of Payment Systems 



Inc. 



Description: Under the original mandating legislation for 
the Medicare fee schedule, the relative values for practice 
expenses are based on historical charges. This method has 
been widely criticized for not being based on the costs of 
providing services. This study is an attempt to speedily 
derive relative values for practice expenses that are more 
resource-based than the existing methods. No new data 
collection will be performed under this project. Under this 
study, relative values are derived as a mark-up to the 
relative values for work. 

Status: The final report was delivered in May 1996, and is 
available from the National Technical Information 
Service, accession number PB96-2 14762. 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



45 



95-013 Derivation of Relative Values for Practice 
Expenses Using Extant Data: Rand Corporation 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



500-92-0023DO10 

May 1995-March 1996 

S 61,075 

Delivery Order from Master Contract 



Daniel Dunn, Ph.D. 

Rand Corporation 

(Seepage 194) 
HCFA Project Jesse M. Levy, Ph.D. 
Officer: Division of Payment Systems 

Description: Under the original mandating legislation for 
the Medicare fee schedule, the relative values for practice 
expenses are based on historical charges. This method has 
been widely criticized for not being based on the costs of 
providing services. This study is an attempt to speedily 
derive relative values for practice expenses that are more 
resource-based than the existing methods. No new data 
collection will be performed under this project. Under this 
study, relative values are derived as a function of time. 

Status: The final report was delivered in April 1996. The 
report is available through the National Technical 
Information Service. The accession number for the final 
report is PB96-2 10851. The accession number for the 
report appendices is PB96-2 14994. 

91-073 Design and Evaluation of a Prospective 
Payment System for Ambulatory Care 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



17-C-90057/5 
September 1991-March 3: 
$ 950,849 
Cooperative Agreement 



1995 



Richard Averill 

3M-Health Information Systems 

100 Barnes Road 

Wallingford, CT 06492 

Joseph M. Cramer 

Division of Payment Systems 

Omnibus Budget Reconciliation Act of 
1986 (Public Law 99-509) 



Description: In 1989, the Health Care Financing 
Administration awarded 3M-Health Information Systems 
(3M-HIS) a 2-year grant to develop a patient- 
classification system that could be used as the basis of 
payment for an outpatient prospective payment system 
(PPS) for Medicare. 3M-HIS finished development of a 
complete set of ambulatory patient groups (APGs) along 
with a set of payment weights and prepared a final report. 



The purpose of this project is to update the prior work 
done on APGs using a new database. The project 
addresses a broad range of issues including care in the 
emergency room, determination of payment for outliers, 
and incorporation of a review of all the basic components 
on an APG-based PPS. The research consists of three 
phases: 

• Phase I: Update the existing APG classification scheme. 

• Phase II: Evaluate APGs using a new database, make 
necessary modifications, compute APG payment 
weights, and simulate an APG-based payment system. 

• Phase III: Propose and test a revision of parts of the 
International Classification of Diseases, 9th Revision, 
Clinical Modification (ICD-9-CM) diagnosis codes. 

Status: 3M-HIS completed development of Version 2.0 of 
the APGs and issued the final report. The final report, 
accession number PB96- 172275, is available from the 
National Technical Information Service. The APG 
definitions manual is also available, accession number 
PB96- 100284. A separate report for Phase III is being 
finalized by the grantee. 

94-074 Design and Implementation of Medicare 
Home Health Quality Assurance Demonstration 



Project No.: 

Period: 

Funding: 

Principal 

Investigator: 

Award: 

Awardee: 



HCFA Project 
Officer: 



500-94-0054 

September 1994-May 1999 

$ 3,234,881 

Peter W. Shaughnessy, Ph.D. 

Contract 

Center for Health Policy Research 

1355 South Colorado Boulevard, Suite 706 

Denver, CO 80222 

Elizabeth Mauser, Ph.D. 

Division of Aging and Disability 



Description: Currently, Medicare's home health survey 
and certification process is primarily focused on structural 
measures of quality. Although this process provides 
important information about home health care, an 
approach based on patient outcome measures would 
substantially increase the Medicare program's capacity to 
assess and improve patient well-being. To address this 
need, the Medicare home health quality demonstration 
will test an approach to developing outcome-oriented 
quality assurance and promoting continuous quality 
improvement in home health agencies. The demonstration 
is designed to serve two purposes: increase Health Care 
Financing Administration's capacity to assess the quality 
of Medicare home health care services and increase home 
health care agencies' ability to systematically evaluate and 
improve patient outcomes. The proposed quality 
assurance approach would complement existing home 



46 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



health certification and review programs and could be 
used with current survey and certification and peer review 
organization intervening care screen approaches. The 
study's conceptual framework for home health quality 
assessment is based on home health outcomes measures 
developed under a HCFA-funded study by the University 
of Colorado, entitled "Development of Outcome-Based 
Quality Measures in Home Health Services" (contract 
number 500-88-0054). 

Status: Fifty agencies have been recruited for this 
demonstration and began demonstration operations in 
January 1996. In early 1997, agencies will receive their 
first outcome reports. 

90-070 Determining the Appropriateness of 
Reclassifying a V 7 entiIator-Dependent Unit as a 
Rehabilitation Unit for Purposes of Reimbursement: 
Pennsylvania (Formerly, Determining the 
Appropriateness of Reclassifying a Ventilator- 
Dependent Unit as a Rehabilitation Unit for 
Purposes of Reimbursement) 

Project No.: 29-P-99401/3 

Period: October 1989-June 1994 

Funding: Waiver only 

Award: Grant 

Principal 

Investigator: Gerard J. Criner, M.D. 

Awardee: Temple University Hospital 

Philadelphia. PA 19140 
HCFA Project Michael Henesch 
Officer: Division of Payment Systems 

Mandate: Medicare Catastrophic Coverage Act of 

1988 (Public Law 100-360) 

Description: Four sites implemented the demonstration: 
Mayo Foundation in Rochester, Minnesota; RMS Health 
Providers in Chicago, Illinois; Sinai Hospital in Detroit, 
Michigan; and Temple University Hospital in 
Philadelphia, Pennsylvania. The demonstration was used 
to determine the appropriateness of reclassifying 
ventilator-dependent hospital components as 
rehabilitation units for purposes of Medicare reimburse- 
ment. The demonstration period was for 3 years 
corresponding to each site's fiscal year. Start dates ranged 
from July 1, 1991, to July 1, 1992. Standard admission 
criteria for use across the sites were developed in 
cooperation with the demonstration sites and are used by 
the professional review organization to evaluate 
admissions and discharges. An empirical analysis was 
conducted to compare the cost of the services, quality of 
care, and patient outcomes for demonstration patients to 
patients in a control group. The analysis also examined 
the demonstration sites, as well as alternative care settings 
in the private sector, to evaluate the effect of 



modifications in reimbursement policy shifting from a 
prospective payment system for these units to the Tax 
Equity and Fiscal Responsibility Act (TEFRA) method of 
reimbursement. Based on the results of the evaluation, the 
Health Care Financing Administration is better able to 
determine the appropriate policy for paying for the 
hospital care of chronic ventilator patients. 

Status: Data collection was completed at each site and the 
final evaluation was completed August 15, 1996. This site 
was scheduled to conclude operating under the 
demonstration on June 30, 1994. A continuation of the 
demonstration for an additional 3 years, retroactively 
from July 1, 1994, was granted at this site only, to allow 
the site the time to integrate the ventilator unit into the 
hospital's skilled nursing facility. This will permit them 
to continue receiving reimbursement under TEFRA 
reimbursement principles. 

91-075 Developing Cost Control Policies for 
Medicare Outpatient Services 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



17-C-90036/3 

September 1991— September 1996 

$ 385,092 

Cooperative Agreement 

Margaret Sulvetta 
Urban Institute 
2100 M Street, NW. 
Washington, DC 20037 
Mark A. Krause, Ph.D. 
Division of Payment Systems 

Omnibus Budget Reconciliation Act of 
1986 (Public Law 99-509) 



Description: The objective of this project is to provide the 
Health Care Financing Administration with information 
to design cost control policies for care delivered in 
hospital outpatient departments. In particular, the 
information will be useful in the development of a 
prospective payment system for such services. The study 
principally addresses these questions: 

• What are the average costs and the group variation of 
costs defining the units of service to bundle different 
ranges of ancillary services? 

• What are the technical implications of bundling 
payment for physicians' services with those of facility 
payment? 

• What affiliation patterns do physicians have with 
hospitals, and is physicians' work concentrated among 
very few facilities? 

• What proportion of the growth in outpatient 
expenditures is attributable to general inflation, service- 
specific inflation, increases in visits, increases in 
services per visit, or a shift in the types of services? 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



47 



• How do charges. Medicare calculated costs, and 
resource costs (from the Center for Health Policy 
Studies' analysis) compare absolutely and relatively? 

Status: Urban Institute was awarded a 12-month 
competing continuation to complete a descriptive and a 
hospital impact analysis of the Ambulatory Patient Group 
(APG) Version 2.0 prospective payment system developed 
by 3M-Health Information Systems (3M-HIS). The data to 
be used in this analysis consist of a representative 
beneficiary sample stratified by the size of the facility and 
whether the reason for the visit was procedural, medical, 
or ancillary only. The data file will consist of 1993 
beneficiary claims. The descriptive statistical analysis will 
identify any atypical volume, cost, or charge APG. An 
examination of the coefficient of variation (CV) statistic 
will provide information regarding the grouping of unlike 
procedures and the impact of ancillary packaging on APG 
average charges and costs. Facility-level case-mix indices 
(CMIs) will be calculated for various hospital types (size, 
urban/rural, teaching, etc.). 

The impact analysis will consist of a simulation of what 
types of facilities may gain or lose under APGs paid on an 
average-cost basis and what is the magnitude of the gain 
or loss. Urban will utilize the 1993 outpatient department 
payment methodology by type of facility and compare that 
to the payments under the APG grouping methodology. 
The final report is expected in Winter 1996. 

93-046 Development and Testing of Risk Adjusters 
Using Medicare Inpatient and Ambulatory Data 

(Formerly, Development of Risk-Adjustment Models) 

Project No.: 500-92-002 1DO02 

Period: June 1 993-December 1995 

Funding: $499,911 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Jonathan P. Weiner 

Awardee: Lewin/VHI, Inc. 

(See page 193) 
HCFA Project Melvin J. Ingber, Ph.D. 
Officer: Division of Delivery Systems and 

Financing 

Description: This project continues the development of a 
patient-classification scheme to help determine capitated 
rates for Medicare health maintenance organization 
enrollees based on the expected medical costs of enrollees. 
The system can be used for risk assessment of enrollees in 
health plans and for risk adjustment of payments to the 
plans. 

The system, a revision of ambulatory care groups, uses 
codes from the International Classification of Diseases, 
9lh Revision, Clinical Modification for diagnoses to 



develop classes of diseases, ambulatory diagnosis groups 
(ADGs), each class having similar cost implications for 
the year following the 12-month data collection period. 
The disease classes, along with other variables, are 
entered into a regression model that estimates the future 
cost implications of a person being coded into each of the 
classes. In this modeling, diagnoses from inpatient as well 
as ambulatory records are used. 

Two models were developed. The ADG-major diagnostic 
category (MDC) contains variables which are counts of 
base-year hospitalizations for diseases related to any of a 
set of MDCs in addition to the ADGs. In this model, the 
diagnoses from ambulatory services are used to determine 
the presence of the ADGs. In the ADG-HOSDOM model 
the ADGs are determined by diagnoses from all sources. 
The HOSDOM variable is added to indicate the presence 
of a condition for which patients are frequently 
hospitalized. An actual hospitalization is not required to 
turn on this indicator. 

Validation measures were computed, including R-squares 
and ratios of predicted to actual costs for Randomly 
selected and groups of special characteristics such as age- 
gender groups, people in first year cost quintiles, and 
people with specific diseases. The system development 
and validation were done on the same data set used in 
identifier 93-045. 

Status: The project has been completed. An article on the 
findings has been published in the Health Care Financing 
Review, Spring 1996, Volume 17, Number 3. 

94-1 1 1 Development of a Physician Prospective 
Payment System for Ambulatory Care 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



17-C-90309/5 

September 1994-March 1996 

$421,451 

Cooperative Agreement 

Merritt R. Marquardt 
Minnesota Mining and 
Manufacturing Company 
Health Information Systems 
St. Paul, MN 55144-1000 
Mark A. Krause, Ph.D. 
Division of Payment Systems 



Description: The objective of this project is to develop for 
the Health Care Financing Administration a new patient 
classification system that can be used as a basis for a 
prospective payment system (PPS) for physician services. 
The new patient-classification system will be based on a 
previously developed patient classification system for the 
facility component of outpatient services constructed by 
3M-Health Information Systems. This system called 



48 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



ambulatory patient groups (APGs) has been in existence 
since 1990 and is being employed as a payment 
methodology by several payers. This physician PPS 
analysis will augment the APGs to encompass the 
professional as well as the facility component of 
ambulatory care. The classification methodology will be 
called physician care groups (PCGs). The development of 
PCGs will be based on a comprehensive analysis of the 
Medicare physician-payment database as well as on other 
non-Medicare databases. The completion of this research 
will provide an alternative classification system for the 
payment of physicians that, in combination with the 
APGs, may provide a coordinated basis for the 
implementation of a PPS for both the professional and 
facility costs of ambulatory care. 

Status: The project start was delayed until work on the 
ambulatory-patient-group system was completed under 
contract 17-C-90057/5. Data development for this 
analysis has begun. A 12-month, no-cost extension has 
been requested and is under consideration. 

94-101 Development of a Risk- Adjustment System 
under Health Reform: Lewin/VHI, Inc. 

Project No.: 500-92-002 1DO05 

Period: July 1994-March 1997 

Funding: $ 1,028,822 

Award: Delivery Order in a Master Contract 

Principal 

Investigator: Allen Dobson, Ph.D. 

Awardee: Lewin/VHI, Inc. 

(See page 193) 
HCFA Project Cynthia G. Tudor, Ph.D. 
Officer: Division of Delivery Systems and 

Financing 

Description: Under this project, two previously developed 
risk adjustment systems will be modified and combined. 
Payment amounts for capitated systems were originally 
developed for the Medicare population and are based 
primarily on diagnoses associated with inpatient hospital 
stays. Ambulatory care groups were developed from data 
for the population under 65 years of age and are based on 
diagnoses found in outpatient claims for physician 
services. These risk-adjustment systems will be combined 
and calibrated on a data set representing several types of 
insurers: a large health maintenance organization; 
Federal employees' health benefit (FEHB) program data 
from Blue Cross/Blue Shield; and Medicaid data from the 
State of Washington. The project also will examine the 
utility of incorporating reinsurance and flat payments 
(i.e., "carve-outs") for high-cost episodes in a risk 
adjustment system for non-Medicare populations. 

Status: The first phase of the project focused on the 
analyses of alternative schemes of reinsurance and high- 



cost carve-out based on the FEHBP and Washington State 
Medicaid data. The contractor analyzed insurance 
arrangements and carve-outs. Results showed the stop- 
loss premiums might range as high as 41 percent of the 
premium (at percent coinsurance and $5,000 stop loss). 
The analysis of carve-outs showed that the incidence of 
the most common conditions on the carve-out list varied 
substantially across the three data sets, suggesting 
potential problems in the definitions of carve-out 
conditions. The second phase of the project will 
incorporate changes to the risk adjuster for the non- 
Medicare population that are similar to those made in the 
development of ambulatory care groups ( ACGs) for the 
Medicare population. A report on these changes is 
expected in early 1997. 

94-016 Development of a Risk-Adjustment System 
Under Health Reform: Rand Corporation 

Project No.: 500-92-0023DO09 

Period: July 1994-June 1996 

Funding: $733,133 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Grace M. Carter, Ph.D. 

Awardee: Rand Corporation 

(Seepage 194) 
HCFA Project Melvin J. Ingber, Ph.D. 
Officer: Division of Delivery Systems and 

Financing 

Description: This project will develop a risk-assessment 
and risk-adjustment system for the non-Medicare 
population. It proposes to combine a diagnosis-based 
system for grouping episodes of illness to determine a 
basic capitation level, prospective payment for particular 
episodes, and reinsurance as a risk-reducing system. A 
modified diagnosis-group severity system will be the basis 
for defining types of episodes. The classification system 
developed at Value Health Sciences is the basis for the 
system. It groups diseases according to codes from the 
International Classification of Diseases, 9th Revision, 
Clinical Modification. The system could be used to assess 
the expected costs of health plan enrollees and to adjust 
payments to the plans. A theoretical model of provider 
behavior is to be developed as a guide to structuring a risk 
adjustment and reinsurance scheme. Data from Michigan 
Medicaid and commercial data are being analyzed. 

Status: Clinical modeling has been done. The data have 
been cleaned for analysis. The final disease groups in the 
model are being determined with a hierarchy of severity 
used for some conditions. 

94-1 17 Development of Global Risk Assessment Models 

Project No.: 17-C-90433/9 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



49 



Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



September 1 994-September 1995 
S 505,694 
Cooperative Agreement 



Mark Hornbrook 

Kaiser Foundation Research Institute 

1 800 Harrison Street 

Oakland, CA 94612 
HCFA Project Melvin J. Ingber, Ph.D. 
Officer: Division of Delivery Systems and 

Financing 

Description: The goal of this project is to develop an 
implementable risk adjuster covering all age groups. It 
will be based on data from health maintenance 
organizations (HMOs), such as Kaiser Northwest, Kaiser 
Ohio, Health Partners, and Group Health Cooperative of 
Puget Sound. The classification system developed at 
Kaiser, clinical-behavioral diagnosis groups, will be 
revised and elements used in a regression model based on 
diagnoses and demographics. Diagnosis codes from the 
International Classification of Diseases, 9th Revision, 
Clinical Modification are the basis for the system. The 
classification would reflect HMO practices and could be 
used to assess the expected costs of individuals or groups 
with respect to each other. It is intended that the system 
could be used to determine capitated payment for 
Medicare enrollees based on premiums for the non- 
Medicare population. 

Status: This project is in the final stages. 

96-039 Disenrollment and Selection Experience 
Under the Medicare HMO Risk Program: 
Task Order: University of Minnesota 

Project No. : 500-95-0053TO02 

Period: July 1996-March 1997 

Funding: $ 136,334 

Award: Task Order in Basic Order Contract 

Principal 

Investigator: Bryan Dowd 

Awardee: University of Minnesota 

(See page 199) 
HCFA Project Melvin J. Ingber, Ph.D. 
Officer: Division of Delivery Systems and 

Financing 

Description: A series of analyses comparing Medicare 
health-maintenance-organization (HMO) joiners and 
disenrollees to beneficiaries in fee-for-service will be 
conducted. Among differences measured will be prior use 
characteristics such as hospitalization and costs; 
mortality; and occurrence of selected procedures after 
disenrollment. Methods will include logistic models for 
probability of joining an HMO conditioned on prior use, 



and probability of an event after disenrollment. Data used 
are for counties with at least 1 ,000 HMO enrollees in the 
years 1993 and 1994. 

Status: The analytical methods have been refined, and the 
databases drawn for the project. 

95-019 Durable Medical Equipment 
Supplier Product and Cost Study 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandates: 



500-95-0044 

September 1995-June 1996 

$ 77,862 

Contract 

George Kowalczyk 
Jing Xing Health and 
Safety Resources Inc. 
7008-K Little River Turnpike 
Annandale, VA 22003 
William J. Sobaski 
Division of Payment Systems 

1994 Amendments to the Social Security 
Act, Section 135, Public Law 103-432 



Description: Section 135 of the 1994 Amendments to the 
Social Security Act mandated that the Administrator of 
the Health Care Financing Administration (HCFA), in 
consultation with appropriate organizations: 

• Collect data on supplier costs of durable medical 
equipment (DME) covered by Medicare. 

• Determine the proportions of costs attributable to the 
service and product components of furnishing such 
equipment. 

• Determine the extent to which these proportions vary by 
type of equipment and by geographic region. 

This project intends to assist HCFA in meetings with 
representatives of the durable medical equipment industry 
to obtain the data needed for this study. 

Status: This project has been completed. The contractor 
assisted in the conduct of meetings with representatives of 
the DME suppliers and with a panel of Federal experts; 
performed a literature review; identified and analyzed 
extant data; and defined several alternative approaches for 
constructing payment adjustments by equipment type and 
geographic region. Suitable data for providing specific 
answers on the proportions of supplier costs attributable to 
the service and product components and the extent to 
which these proportions vary by type of equipment and 
geographic regions were sought but could not be obtained. 
The contractor concluded that construction of a 



50 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



geographic payment index for DME will be challenging 
because of the: 

• Inability of DME suppliers to readily provide the kinds 
of item specific cost data normally used by HCFA in 
developing geographic payment indices. 

• Lack of data and standardization on cost shares by 
product type. 

• Likely objections that would be raised by any 
methodology that estimates cost shares and geographic 
variation using proxy data. 

Copies of this report will be sent to the chairmen of the 
Committees on Energy and Commerce, and on Ways and 
Means of the House of Representatives and the Committee 
on Finance of the Senate. 

93-093 Effects of Geographic Variations on Medicare 
Capitation Rates for the Social Health Maintenance 
Organization, Program for All-inclusive Care for the 
Elderly, and Community Nursing Organization 
Projects (Formerly, Long-Term Care Studies 
(Section 207)) 



94-063 Effects of Telemedicine on Accessibility, 
Quality, and Cost of Health Care 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



500-89-0047/40 

August 1 993-November 1994 

S 116,200 

Contract 



David Kennell 

Lewin/VHI, Inc. 

(See page 17) 
HCFA Project Carolyn Rimes 
Officer: Division of Aging and Disability 

Description: The current method of determining 
capitation payments to be made by Medicare for several 
demonstration programs (including the Social Health 
Maintenance Organization, Program for All-inclusive 
Care for the Elderly, and Community Nursing 
Organization) is based on the adjusted average per capita 
cost methodology, which was developed to establish 
capitation rates for the Tax Equity and Fiscal 
Responsibility Act health maintenance organizations. In 
the above demonstration programs, case-mix models were 
developed that included individual limitations in activities 
of daily living and instrumental activities of daily living. 
These variables are not available for all Medicare 
recipients; consequently, the local area adjustment needed 
to measure the cost of enrolling a particular set of persons 
cannot be made in the usual manner. In this study, 
synthetic estimates are used to develop appropriate 
geographic adjustments that can be used in conjunction 
with national-level data in establishing capitation rate 
formulas for these and other potential demonstrations. 

Status: This methodology is complete and is a component 
in developing capitation payments. 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-90332/5 

July 1994-July 1997 

$ 644,086 

Grant 

F. W. Womack 

University of Michigan 

3003 South State Street 

Ann Arbor, MI 48109-1274 

Lawrence E. Kucken 

Division of Health Information and 

Outcomes 



Description: This project is evaluating the effect of 
telemedicine systems on accessibility, quality, and cost of 
health care. A detailed methodology for evaluating 
telemedicine is being developed by a panel of experts and 
implemented in existing telemedicine programs at the 
Medical College of Georgia (MCG) Telemedicine Center 
and Mountaineer Doctor Television (MDTV) at the 
Health Sciences Center, West Virginia University (WVU). 
Included in the evaluation design are a quasi- 
experimental survey study of clients and providers in 
selected experimental and control communities and a case 
control study to compare the content, process, and 
outcomes of episodes of care with and without 
telemedicine. The project plan has three goals: 

• Development of a detailed methodology for a 
comprehensive evaluation of the effects of telemedicine 
on accessibility, utilization, quality, and cost of health 
care, using a panel of experts on quality, economics, 
clinical medicine, and technology. 

• Implementation and testing of the evaluation design at 
the MCG Telemedicine Center. 

• Extending the evaluation design to MDTV at WVU. 

The general hypothesis guiding this research is that 
telemedicine will improve accessibility to health care, 
enhance the quality of care delivered, and contain costs. 

Status: Data collection is under way and is expected to be 
completed by March 1997. 

94-100 Enrollment and Utilization Across 
Medicare Supplemental Plans 



Project No.: 


17-C-90328/1 


Period: 


September 1 994-September 1996 


Funding: 


$ 207,276 


Award: 


Cooperative Agreement 


Principal 




Investigator: 


Rezaul Khandker, Ph.D. 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



51 



Awardee: Center for Health Economics Research 

300 Fifth Avenue, 6th Floor 
Waltham, MA 02154 

HCFA Project Brigid Goody, Sc.D. 

Officer: Division of Delivery Systems and 

Financing 

Description: This study investigates variations in 
enrollment and utilization across Medicare supplemental 
plans to identify patterns and determinants of enrollment 
in supplemental insurance policies and describes the 
effects of these policies on the utilization of health care 
services by beneficiaries with differing characteristics and 
health status. There are three study questions: 

• What factors account for beneficiary choice among the 
available options? 

• How does utilization vary among those with and 
without supplemental policies and those with 
supplemental policies of different types? 

• How does supplemental insurance affect beneficiaries' 
satisfaction with their health insurance coverage? 

The study uses data from the Medicare Current 
Beneficiary Survey (1991-93), Medicare Part A and B 
records merged with survey respondents, and the area 
resource file. 

Status: The final report, "Enrollment and Utilization 
Across Medicare Supplemental Plans," presents the 
results of descriptive and multivariate analyses of 
enrollment in supplemental plans and utilization of and 
expenditures on Medicare-covered services. Principal 
findings include: 

• 77 percent of Medicare beneficiaries have private 
supplemental coverage and an additional 12 percent 
receive supplemental coverage through the Medicaid 
program. 

• Gender, race/ethnicity, education, income, and health 
status are significant determinants of having 
supplemental coverage. 

• Medicare beneficiaries with any type of private or 
public supplemental coverage have a higher probability 
of incurring Medicare expenditures. 

• Relative to those without Medicare supplemental 
insurance, total Medicare spending is 15.1 percent 
higher to those with individually purchased 
supplemental coverage to as much as 32.2 percent 
higher for those with both individual and employer 
plans. 

96-083 ESRD Managed-Care Demonstration: 
Health Options 

Project No.: 95-C-90692/4 

Period: September 1 996-September 2000 

Funding: Waiver only Project 

Award: ( ooperative Agreement 



Principal 

Investigator: Bruce Davidson, SVP 

Awardee: Health Options, Inc. 

532 Riverside Avenue 

P. O. Box 60729 

Jacksonville, FL 32236-0729 
HCFA Project Michael Kendix, Ph.D. 
Officer: Division of Health Information and 

Outcomes 

Mandates: Section 13567(b) of the Omnibus Budget 
Reconciliation Act of 1993 
(Public Law 103-66) 

Description: At present, end stage renal disease (ESRD) 
patients cannot enroll in health maintenance 
organizations under Medicare contracts, but may remain 
in if they develop ESRD after enrollment. The current 
ESRD capitation payment is State-specific, but 
unadjusted, and based on 95 percent of fee-for-service 
costs. Under the demonstration, rates will be paid on the 
basis of treatment status (maintenance dialysis, transplant 
episode, or functioning graft), and adjusted for patient age 
and whether diabetes was the cause of kidney failure. 
Demonstration rates are based on 1 00 percent of fee-for- 
service costs, and additional non-Medicare-covered 
benefits are to be provided. 

The demonstration will test whether: 

• Year-round open enrollment of Medicare's ESRD 
patients in managed care is feasible. 

• Integrated acute and chronic care services, and case 
management for ESRD patients, improves health 
outcomes. 

• Capitation rates reflecting patients' treatment needs 
increases the probability of kidney transplant 

• The additional benefits are cost effective. 

Health Options currently has 271 ESRD patients enrolled 
under its Medicare risk contract, and there are 4,788 
ESRD patients eligible for the demonstration in the 
service area of Dade, Broward, and Palm Beach counties. 
Health Options intends to expand its contractual 
relationships with renal providers. The nephrologist will 
function as the primary care physician and will employ a 
nurse practitioner for the case-management team. The 
additional benefits include health education and 
promotion, including a diabetes management program; 
prescription drugs; nutritional supplements; 
transportation to dialysis; rehabilitation; and nursing 
home dialysis services. Out-of-area dialysis will be 
covered for up to 30 days per year. 

Status: The project is beginning a 1-year planning and 
development period that is to be followed by 3 years of 
service delivery. 



52 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



96-084 ESRD Managed-Care Demonstration: 
Kaiser Foundation Health Plan, Southern California 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandates: 



95-C-90695/9 

September 1 996-September 2000 

S 175,000 

Cooperative Agreement 

Melodi Shapiro 

Kaiser Foundation Health Plan, Inc. 

393 East Walnut Street 

Pasadena, CA 91188 

Bonnie M. Edington 

Division of Health Information and 

Outcomes 

Section 13567(b) of the Omnibus Budget 
Reconciliation Act of 1993 
(Public Law 103-66) 



Description: At present, end stage renal disease (ESRD) 
patients cannot enroll in health maintenance 
organizations under Medicare contracts, but may remain 
in if they develop ESRD after enrollment. The current 
ESRD capitation payment is State-specific, but 
unadjusted, and based on 95 percent of fee-for-service 
costs. Under the demonstration, rates will be paid on the 
basis of treatment status (maintenance dialysis, transplant 
episode, or functioning graft), and adjusted for patient age 
and whether diabetes was the cause of kidney failure. 
Demonstration rates are based on 100 percent of fee-for- 
service costs, and additional non-Medicare-covered 
benefits are to be provided. 

The demonstration will test whether: 

• Year-round open enrollment of Medicare's ESRD 
patients in managed care is feasible. 

• Integrated acute and chronic care services, and case 
management for ESRD patients, improves health 
outcomes. 

• Capitation rates reflecting patients' treatment needs 
increases the probability of kidney transplant. 

• The additional benefits are cost effective. 

Kaiser's proposed service area is Los Angeles, Orange, 
Riverside, San Bernardino, and San Diego Counties, in' 
which there are approximately 13,000 ESRD patients; 
2,000 are currently enrolled in Kaiser's Medicare risk 
contract. Kaiser currently has 1 hemodialysis and 
6 peritoneal dialysis units, and contracts with 
120 nephrologists, 1 12 dialysis facilities, and 3 transplant 
facilities. Under the demonstration, Kaiser will build on 
its registered nurse case management model, integrating a 
diabetes education coordinator into the team, and may 
credential dialysis providers, potentially using a 
450-indicator assessment tool. 



Additional benefits include intensive case management; 
enhanced health education and family supportive services, 
particularly for diabetics; nutritional supplements; and 
60 days out-of-area dialysis during travel. 

Status: The project is beginning a 1-year planning and 
development period that is to be followed by 3 years of 
service delivery. 

96-085 ESRD Managed-Care Demonstration: 
PacifiCare of California 

Project No.: 95-C-90699/9 

Period: September 1 996-September 2000 

Funding: $ 175,000 

Award: Cooperative Agreement 

Principal 

Investigator: William J. Osheroff, M.D. 

Awardee: PacifiCare of California 

5701 Katella Avenue 

Cypress, CA 90630-5019 
HCFA Project Bonnie M. Edington 
Officer: Division of Health Information and 

Outcomes 

Mandates: Section 13567(b) of the Omnibus Budget 
Reconciliation Act of 1993 
(Public Law 103-66) 

Description: At present, end stage renal disease (ESRD) 
patients cannot enroll in health maintenance 
organizations under Medicare contracts, but may remain 
in if they develop ESRD after enrollment. The current 
ESRD capitation payment is State-specific, but 
unadjusted, and based on 95 percent of fee-for-service 
costs. Under the demonstration, rates will be paid on the 
basis of treatment status (maintenance dialysis, transplant 
episode, or functioning graft), and adjusted for patient age 
and whether diabetes was the cause of kidney failure. 
Demonstration rates are based on 100 percent of fee-for- 
service costs, and additional non-Medicare-covered 
benefits are to be provided. 

The demonstration will test whether: 

• Year-round open enrollment of Medicare's ESRD 
patients in managed care is feasible. 

• Integrated acute and chronic care services, and case 
management for ESRD patients, improves health 
outcomes. 

• Capitation rates reflecting patients' treatment needs 
increases the probability of kidney transplant. 

• The additional benefits are cost effective. 

PacifiCare proposes a demonstration in 2 sites: 4 counties 
in Northern California, in which there are 4,000 ESRD 
patients, and 9 counties in Southern California, in which 
there are 14,000 ESRD patients. Currently, PacifiCare has 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



568 ESRD patients enrolled and contracts with 
38 medical and nephrology groups (163 nephrologists), 
93 dialysis units, and 12 transplant centers. Under the 
demonstration, the nephrologist will be the primary care 
physician and will head a multi-disciplinary team. 
Registered nurse field case managers will coordinate 
individual patient care across settings and in collaboration 
with other team members. A central case manager will 
integrate standards and clinical protocols and oversee 
provider education. Five ESRD specific provider- 
education tools will be developed. PacifiCare has 
developed a series of ESRD guidelines; at least eight other 
ESRD guidelines will be developed under the 
demonstration. 

Additional benefits include prescription drugs; non- 
prescription medications; liquid nutritional supplements; 
routine vision and dental care; transportation to dialysis 
and medical appointments; out-of-area maintenance 
dialysis for up to 2 weeks per year; 80 hours respite care; 
personal care and homemaking services; and 
rehabilitation. 

Status: The project is beginning a 1-year planning and 
development period that is to be followed by 3 years of 
service delivery. 

96-086 ESRD Managed-Care Demonstration: 
Phoenix Healthcare of Tennessee 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandates: 



95-C-90696/4 

September 1 996-September 2000 

$ 150,000 

Cooperative Agreement 

Susan Cooper, R.N. 

Phoenix Healthcare of Tennessee 

3401 West End Avenue, Suite 470 

Nashville, TN 37203-1069 

Michael Kendix, Ph.D. 

Division of Health Information and 

Outcomes 

Section 13567(b) of the Omnibus Budget 
Reconciliation Act of 1993 
(Public Law 103-66) 



Description: At present, end stage renal disease (ESRD) 
patients cannot enroll in health maintenance 
organizations (HMOs) under Medicare contracts, but may 
remain in if they develop ESRD after enrollment. The 
current ESRD capitation payment is State-specific, but 
unadjusted, and based on 95 percent of fee-for-service 
costs. Under the demonstration, rates will be paid on the 
basis of treatment status (maintenance dialysis, transplant 
episode, or functioning graft), and adjusted for patient age 
and whether diabetes was the cause of kidney failure. 
Demonstration rates are based on 100 percent of fee-for- 



service costs, and additional non-Medicare-covered 
benefits are to be provided. 

The demonstration will test whether: 

• Year-round open enrollment of Medicare's ESRD 
patients in managed care is feasible. 

• Integrated acute and chronic care services, and case 
management for ESRD patients, improves health 
outcomes. 

• Capitation rates reflecting patients' treatment needs 
increases the probability of kidney transplant. 

• The additional benefits are cost effective. 

Phoenix Healthcare of Tennessee is a State-licensed HMO 
contracting with TennCare, Tennessee's Medicaid- 
waivered health care reform demonstration project. 
Current enrollment consists of approximately 42,000 
TennCare and 500 commercial members. Under the 
demonstration, Phoenix will be closely partnered with 
Nephrology Associates, a 14-member physician group, 
and will contract with Gambro Healthcare and Dialysis 
Clinics, Inc. (DCI) for the provision of outpatient dialysis 
services and home dialysis training. Gambro and DCI 
operate 18 outpatient dialysis facilities in the service area. 
The service area consists of 40 counties surrounding 
Nashville, an area containing approximately 1,400 ESRD 
patients. Nephrology Associates serves approximately 
60 percent of these patients. 

The nephrologist will be the primary care physician under 
the demonstration, and will be supported by a team of 
nurse case managers, dietitians, and social workers 
employed by Nephrology Associates. The additional 
benefits offered will include an introductory home visit; 
preventive health services, including diagnostic tests, 
immunizations, and health education and counseling; 
transportation to dialysis; nutritional supplements; and 
some prescription and over-the-counter drugs. 

Status: The project is beginning a 1-year planning and 
development period that is to be followed by 3 years of 
service delivery. 

94-106 Evaluating Alternative 
Risk Adjusters for Medicare 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



17-C-90316/1 
September 1994-March 
$ 327,560 
Cooperative Agreement 



997 



Gregory C. Pope 

Center for Health Economics Research 

300 Fifth Avenue, 6th Floor 

Waltham, MA 02154 

Sherry A. Terrell, Ph.D. 

Division of Delivery Systems and 

Financing 



54 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



Description: This project will use a variety of health status 
measures (e.g., functional limitations, chronic conditions, 
perceived health status) from the Medicare Current 
Beneficiary Survey (MCBS), along with the traditional 
adjusted average per capita cost factors to predict future 
expenditures for the purpose of risk adjustment. 

Alternative risk adjusters also will be evaluated. That is, 
the predictive accuracy of survey-based risk adjusters from 
the MCBS will be compared to claims-based risk adjusters 
that have been developed (e.g., diagnostic-cost groups, 
ambulatory care groups, payment amount for capitated 
systems). This project also will examine the stability of 
health status risk adjusters over time. 

Status: Database construction and variable construction 
have been completed. Year 01 preliminary regression 
analyses suggested that chronic conditions are the single 
most powerful set of risk factors that explain total 1992 
Medicare reimbursement. Dual Medicaid enrollment is 
also predictive of future Medicare expenditures. In 
Year 02 of the study, weighted least squares (WLS) was 
chosen as the final functional model form after comparing 
WLS, log expenditures, top-coded expenditures, and the 
Rand two-part models. The chronic conditions model has 
the highest explanatory power among the survey-based 
variables (e.g., self-rated health status and functional 
status). The survey-based variables, however, are 
outperformed by the Hierarchical Coexisting Condition 
(HCC) and prior use models. Sensitivity analyses which 
compared models using 1991 attributes to predict 1992 
expenditures with models using 1992 attributes to predict 
1993 expenditures indicate regression coefficient 
sensitivity to sample characteristics such as outliers. A 
validation analysis comparing predicted 1993 
expenditures to actual 1 993 expenditures for various 
subgroups (e.g., by self-rated health status) is near 
completion. Other analyses in progress include 
comparisons of alternative validation measures (e.g., 
R-squares), stability of health status measures, decay in 
the explanatory power of such measures, and risk 
adjusters for Medicare non-covered and total 
expenditures. A final report is expected in Spring 1997. 

95-004 Evaluation of Case Classification Systems 
and Design of a Prospective Payment Model for 
Inpatient Rehabilitation 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigators: 

Awardee: 



500-92-0023 

September 1995— January 1997 

$ 453,847 

Cooperative Agreement 

Grace M. Carter, Ph.D., and 
Joan Buchanan, Ph.D. 
Rand Corporation 

(See page 194) 



HCFA Project William Buczko, Ph.D. 
Officer: Division of Payment Systems 

Description: This project will evaluate the utility of 
functional assessment measures and the appropriateness 
of a patient classification system developed by the 
University of Pennsylvania Medical School (functional 
related groups)for reimbursement of Medicare inpatient 
rehabilitation. Based on this evaluation, the contractor 
will construct a model of a prospective reimbursement 
system for inpatient rehabilitation under Medicare. 

Status: Technical evaluation panels for evaluation of 
functional assessment measures and patient classification 
systems met in November 1995 and January 1996. Data 
analysis began in late 1995. Replication of the 
classification analysis used to create functional related 
groups based on 1994 data has been completed and 
presented in a draft report. 

Creation of group weights, outlier definitions and 
estimates, facility-level case-mix indices, and other 
payment adjustors will be completed by October 1996. 
Payment simulations comparing case-mix-adjusted 
prospective models to current Tax Equity and 
Fiscal Responsibility Act payments will begin in 
November 1996. 

93-075 Evaluation of Cost HMOs and 
Health Care Prepayment Plans 

Project No.: 500-92-001 1DO03 

Period: September 1 993-November 1996 

Funding: $ 538,869 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Randall S. Brown, Ph.D. 

Awardee: Mathematica Policy Research, Inc. 

(See page 65) 
HCFA Project Ronald W. Lambert 
Officer: Division of Delivery Systems and 

Financing 

Description: The awardee will evaluate the cost 
effectiveness of health maintenance organizations 
(HMOs) and health care prepayment plans (HCPPs) 
compared with fee-for-service and risk HMOs. A separate 
assessment of organizations that have recently converted 
from the risk option to either of the cost-based options 
will be conducted. The main question for this assessment 
is whether the Health Care Financing Administration 
(HCFA) would have saved or lost money had these 
organizations remained risk contractors. A case study of 
HCPPs will be conducted to determine the operational 
characteristics of the various types of HCPPs. The 
evaluator will also examine how HCPPs coordinate the 
delivery of health services, given that it is not subject to 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



55 



the same regulator) requirements as risk or cost 
contractors. 

Status: This project is near completion. Preliminary 
findings indicate that the cost-based program is not cost 
effective to HCFA. Overall, HCFA's payments for cost- 
based enrollees in 1993 were higher than estimated had 
these enrollees been in fee-for-service or enrolled in risk 
plans. The main reason for this appears to be a lack of 
incentive for plans to drive hard bargains with physicians 
on prices, salaries, or capitation rates. The final report, 
due November 1996, will include estimates of the extent 
of the losses to HCFA under cost-based programs 
compared to fee-for-service and risk plans. 

96-081 Evaluation of Group-Specific Volume 
Performance Standards Demonstration: 
Task Order: Health Economics Research, Inc. 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 



Awardee: 



HCFA Project 
Officer: 



500-95-0048 

September 1996-June 2001 
$ 1,697,773 
Task Order 

Janet B.Mitchell, Ph.D. 

Gregory C. Pope, Ph.D. and 

A. James Lee, Ph.D. 

Health Economics Research, Inc. 

300 Fifth Avenue, 6th Floor 

Waltham, MA 02154 

Teresa L. DeCaro 

Division of Payment Systems 



Description: The purpose of this task order is to 
comprehensively evaluate the Group-Specific Volume 
Performance Standards (GVPS) Demonstration. 
Additionally, there is a group of tasks to provide technical 
support for setting sites' targets and measuring their 
actual performance. The goal of the demonstration is to 
test the feasibility of this partial-risk-bearing payment 
arrangement between the Health Care Financing 
Administration and qualifying physician-based 
organizations in the fee-for-service (FFS) market, 
whereby FFS rules apply within the context of a 
performance target, beneficiaries are not enrolled, and 
physician-sponsored organizations develop structures and 
processes to manage the services and cost of care received 
by FFS patients. 

Status: Initial planning meetings for both technical 
support and evaluation tasks are under way. 

95-006 Evaluation of HMO Outlier Demonstration 



Award: Technical Support: c 

Evaluation of Demonstrations 

Principal 

Investigator: Lyle Nelson, Ph.D. 

Awardee: Mathematica Policy Research, Inc. 

(Seepage 198) 

HCFA Project Ronald W. Lambert 

Officer: Division of Delivery Systems and 

Financing 

Description: The awardee will evaluate the Outlier Pool 
Demonstration. Under this demonstration, participating 
plans in the Seattle area will be paid at a rate of 
97 percent of the adjusted average per capita cost, with 
2 percent of the payments going into a pool. Plans with a 
higher-than-average incidence of high-cost cases will 
receive more from the pool than they paid in, and those 
with a lower incidence will receive less. In this 
evaluation, the awardee will focus on two primary tasks: 

• Examine issues involved in setting up and running an 
outlier pool. 

• Describe the distribution of costs, both of the 
individuals with claims exceeding the outlier threshold 
and the population of the plans' enrollees. 

The awardee will also be responsible for taking the 
encounter data submitted by the plans and constructing a 
person-specific database. This database will be used to 
address the analytical issues under the second task above. 

Status: Due to a delay in implementing the demonstration, 
work on this contract has not yet begun as of 
September 30, 1996. 

94-082 Evaluation of Phase II of the Home Health 
Agency Prospective Payment Demonstration 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



500-94-0062 

September 1 994-September 1999 

$ 3,528,408 

Contract 

Barbara Phillips, Ph.D. 
Mathematica Policy Research, Inc. 
P. O. Box 2393 
Princeton, NJ 08543-2393 
Elizabeth Mauser, Ph.D. 
Division of Aging and Disability 

Omnibus Budget Reconciliation Act of 
1987 (Public Law 100-203) 



Project No.: 500-95-0047TO02 

Period: September 1995-September 

Funding: S 449,297 



998 



Description: This contract will evaluate Phase II of the 
Home Health Agency Prospective Payment 
Demonstration. This demonstration is testing two 
alternative methods of paying home health agencies 
(HHA) on a prospective basis for services furnished under 
the Medicare program. The prospective payment 



56 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



approaches being tested include payments per visit by type 
of HHA visit discipline (Phase I) and payment per episode 
of Medicare-covered home health care (Phase II). 
Implementation of Phase II, which will test the per 
episode payment approach, is scheduled to begin in 
Spring 1995. HHAs that agree to participate are 
Randomly assigned to either the prospective payment 
method or to a control group that continues to be 
reimbursed in accordance with the current Medicare 
retrospective cost system. HHAs will participate for 
3 years. The evaluation will combine estimates of 
program impacts on cost, service use, access, and quality, 
with detailed information on how agencies actually 
change their behavior to produce a full understanding of 
what would happen if prospective payment replaced the 
current cost-based reimbursement system nationally. The 
findings will indicate not only the overall effects of the 
change in payment methodology, but also how the effects 
are likely to vary with the characteristics of agencies and 
patients. This information will be of great value for 
estimating the potential savings from a shift to 
prospective payment for home health care, for indicating 
where potential problems with quality of care might exist, 
and for identifying types of patients who might be at risk 
of restricted access to care as a result of their need for an 
unusually large amount of care. Because of the relatively 
small number of agencies participating, the use of 
qualitative information obtained in discussions with 
agencies concerning their characteristics and behavior 
will be essential for avoiding erroneous inferences. 

Status: The first round of site visits to participating 
agencies has been completed. 

92-068 Evaluation of the Community Nursing 
Organization Demonstration 

Project No.: 500-92-0055 

Period: September 1992-June 1998 

Funding: $ 3,014,634 

Award: Contract 

Principal 

Investigator: Robert J. Schmitz, Ph.D. 

Awardee: Abt Associates, Inc. 

55 Wheeler Street 

Cambridge, MA 02138 
HCFA Project Melissa Hulbert, MPS 
Officer: Division of Aging and Disability 

Mandate: Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 

Description: The Community Nursing Organization 
(CNO) Demonstration was mandated by section 4079 of 
the Omnibus Budget Reconciliation Act of 1987. The 
legislation directs the Secretary of the Department of 
Health and Human Services to conduct a demonstration 



project at four or more sites to test a capitated, nurse- 
managed system of care. The two fundamental elements 
of the CNO are capitated payment and nurse case 
management. These two elements are designed to promote 
timely and appropriate use of community health services 
and to reduce the use of costly acute care services. The 
legislation mandates a CNO service package that includes 
home health care, durable medical equipment, and certain 
ambulatory care services. The CNO sites receive a 
monthly capitation payment for each enrollee. The 
capitation rate is modeled on the average adjusted per 
capita cost-payment method used for Medicare health 
maintenance organizations. The CNO per capita payment 
rate will be set at a level that is equal to 95 percent of the 
adjusted average per capita Medicare payment for 
community and ambulatory services in the CNO's 
geographic area. The legislation mandates the use of 
two types of CNO per capita payment methods. Payment 
Method A adjusts the per capita payment according to an 
individual's age, gender, and prior home health use. 
Payment Method B adjusts the per capita payment 
according to an individual's functional status in addition 
to age, gender, and prior home health use. The evaluation 
of the CNO demonstration will test the feasibility and 
effect on patient care of a capitated, nurse case-managed 
service-delivery model. Both qualitative and quantitative 
components are included in the evaluation design. The 
qualitative component will use a case study approach to 
examine the operational and financial viability of the 
CNO model. The quantitative component will use a 
Randomized design to measure the impact of the CNO 
intervention on mortality, hospitalization, physician 
visits, nursing home admissions, and Medicare expendi- 
tures, as well as on such nurse-sensitive outcomes as 
knowledge of health problems and management of care. 

Status: The four CNO demonstration sites completed a 
1-year developmental period and began a 3 -year 
operational period in January 1994. A 1-year extension of 
the demonstration and evaluation has been granted. 
Collection of baseline data for CNO enrollees began in 
January 1994. Site visit reports summarizing site 
activities for the first and second operational years have 
been completed. An interim report was prepared by the 
evaluation contractor. A second interim report is expected 
in Spring 1997. 

90-065 Evaluation of the Home Health 
Prospective Payment Demonstration 



1995 



Project No.: 


500-90-0047 


Period: 


September 1990— November 


Funding: 


$ 2,858,676 (Phase I) 


Award: 


Contract 


Principal 




Investigator: 


Randall S. Brown, Ph.D. 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



57 



Awardee: Mathematica Policy Research, Inc. 

P. O. Box 2393 

Princeton, NJ 08543-2393 
HCFA Project Elizabeth Mauser, Ph.D. 
Officer: Division of Aging and Disability 

Mandate: Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 

Description: The purpose of this contract is to evaluate 
Phase I of the demonstration designed to test the 
effectiveness of using prospective payment methods to 
reimburse Medicare-certified home health agencies 
(HHA) for services provided under the Medicare program. 
In Phase I, a per visit payment method that sets a separate 
payment rate for each of six types of home health visits 
(skilled nursing, home health aide, physical therapy, 
occupational therapy, speech therapy, and medical social 
services) is being tested. Mathematica Policy Research is 
evaluating the effects of this payment method on HHAs' 
operations, service quality, and expenditures. The 
awardee is also analyzing the relationship between patient 
characteristics and the cost and utilization of home health 
services. 

Status: By October 1994, all demonstration agencies 
exited the demonstration. Mathematica has completed 
their evaluation. The article, "Do Preset Per Visit 
Payment Rates Affect Home Health Agency Behavior?" by 
Phillips, B.R., Brown, R.S., Bishop, C.E., and Klein, A.C. 
discusses preliminary results from Phase I of the 
demonstration and appears in the Health Care Financing 
Administration, Volume 16, Number 1, pp. 91-107, Fall 
1994. Findings from the full demonstration suggest that 
per visit prospective payment had no significant effect on 
quality of care, selection and retention of patients, cost per 
visit, visit volume, use of non-Medicare services, and use 
and reimbursement of Medicare-covered services. But it 
appears that treatment agencies may have responded to 
the opportunities to earn profits under the demonstration 
by increasing their volume of visits faster than they would 
have in the absence of prospective ratesetting. 

93-056 Evaluation of the Medicare Case- 
Management Demonstrations 

Project No.: 500-92-001 1DO02 

Period: July 1993-June 1997 

Funding: S 700,846 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Jennifer Shore 

Awardee: Mathematica Policy Research, Inc. 

(See page 65) 
HCFA Project Leslie M. Greenwald, Ph.D. 
Officer: Division of Delivery Systems and 

Financing 



Mandate: Omnibus Budget Reconciliation ActDf 

1990 (Public Law 101-508) 

Description: The purpose of this contract is to evaluate 
the three Medicare Case-Management Demonstrations. 
These demonstrations were designed to test the 
appropriateness of providing case-management services 
for Medicare beneficiaries with catastrophic illnesses and 
high medical costs. The demonstrations, which operated 
in three sites and focused on number of chronic illnesses 
including congestive heart failure beginning in 1993, 
ended in late 1995. The final evaluation report, which 
will analyze the demonstration's cost effectiveness, and 
impacts on beneficiary outcomes and health status, is 
expected by mid- 1997. 

In an interim evaluation report issued in 1995, analysis of 
the early operational aspects of the demonstration found 
that: 

• Voluntary Medicare beneficiary enrollment consent 
rates in these case-management projects were much 
lower than expected. 

• Despite an extensive outreach effort, physicians were 
less supportive of beneficiary participation in the case 
management program than anticipated. 

• In general, identification and enrollment activities in 
the case-management projects were much more time 
consuming than had been expected. 

The final evaluation of the three demonstration sites will 
use comparisons of claims data and a beneficiary 
participant survey to compare the relative expenditures, 
health outcomes, and health status/functional status of 
beneficiaries with the targeted chronic illnesses who 
received case management, to those who were 
Randomized into a control group (and therefore received 
no case management interventions). It is expected that 
this demonstration, and its evaluation, will provide some 
insight into the operational feasibility and cost 
effectiveness of case management as a way of controlling 
Medicare beneficiaries' catastrophic health care costs and 
improving care in the Medicare fee-for-service sector. 

Status: The evaluation contract was awarded on 
August 1, 1993. Mathematica Policy Research is in the 
final year of the evaluation. 

95-018 Evaluation of the Medicare 
Choice Demonstration 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: Lyle Nelson, Ph.D. 



500-92-0011/6 
September 1995— June 
$ 1,591,240 
Contract 



998 



5X 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



Awardee: Mathematica Policy Research, Inc. 

600 Maryland Avenue 

Washington, DC 20024 
HCFA Project Renee Mentnech 
Officer: Division of Delivery Systems and 

Financing 

Description: The Health Care Financing Administration 
(HCFA) is in the process of implementing the Medicare 
Choice Demonstration to test the feasibility and 
desirability of new types of managed-care plans for 
Medicare such as integrated delivery systems and 
preferred provider organizations. The purpose of this 
evaluation project is to provide a detailed assessment of 
the overall demonstration project, which looks specifically 
at beneficiary experiences in the demonstration, cost and 
use of services within the demonstration sites, and quality 
of care issues. The evaluation will provide some insights 
into whether the greater range of managed-care options 
offered in this demonstration would be more appealing to 
the Medicare beneficiaries, and whether issues such as 
biased selection, high rates of disenrollment, and 
dissatisfaction exist. In addition, the evaluation project 
will provide continuous monitoring of the demonstration 
sites, including a comprehensive case study of each of the 
managed-care plans in the demonstration. This part of the 
evaluation activities will focus on the implementation 
experience and operational feasibility of the new 
managed-care plans, as well as how plans interact with 
carriers and HCFA. 

Status: This project is in the early development stage. 

94-081 Evaluation of the Nursing Home 
Case-Mix and Quality Demonstration 

Project No.: 500-94-0061 

Period: September 1994-September 1999 

Funding: $2,980,219 

Award: Contract 

Principal 

Investigator: Robert J. Schmitz, Ph.D. 

Awardee: Abt Associates, Inc. 

55 Wheeler Street 

Cambridge, MA 02138 
HCFA Project Edgar A. Peden, Ph.D. 
Officer: Division of Payment Systems 

Description: Under the Nursing Home Case-Mix and 
Quality (NHCMQ) Demonstration, the Health Care 
Financing Administration is testing the feasibility of 
paying skilled nursing facilities (SNFs) for Medicare 
skilled nursing services on a prospective basis. Currently, 
SNFs are reimbursed on a retrospective basis for their 
reasonable costs. A case-mix classification, called 
resource utilization groups, is being used to classify 
patients, permitting HCFA to pay facilities for each 



covered day of care, according to the case mix of patients 
residing in the facility on any given day. Though some 
costs will continue to be paid on a retrospective cost basis 
under the demonstration, the prospective rate will 
eventually include inpatient routine nursing costs and 
therapy costs. To guard against the possibility that 
inadequate care would be provided to patients with heavy 
care needs, a system of quality indicators has been 
developed that will be used to monitor the quality of care. 

The demonstration project was implemented in six States 
(Kansas, Maine, Mississippi, New York, South Dakota, 
and Texas) in Summer 1995, with Medicare-certified 
facilities in these States being offered the opportunity to 
participate on a voluntary basis. 

The evaluation of this demonstration project will seek to 
estimate specific behavioral responses to the introduction 
of prospective payment and to test hypotheses about 
certain aspects of these responses. The principal goal of 
the evaluation of the NHCMQ Demonstration is the 
estimation of the effects of case-mix-adjusted prospective 
payment on the health and functioning of nursing home 
residents, their length of stay, and use of health care 
services; on the behavior of nursing facilities; and on the 
level and composition of Medicare expenditures. 

Status: The evaluation design has been finalized and 
visits to a sample of demonstration facilities began. 
Current analytic activities center around sampling and 
data collection. Of special interest is collection of data on 
the provision of therapy services from both demonstration 
sites and comparison sites which will entail some primary 
data collection because the quantity and duration of 
therapies may not be reliably ascertained from Medicare 
claims data. The data collection plan is being developed 
pursuant to an assessment of the form in which most 
facilities maintain their records, and nurses are being 
recruited to abstract medical records. A key issue that will 
be analyzed is whether the probability of discharge or 
transfer changes under case-mix-adjusted prospective 
payment and what circumstances surround discharges or 
transfer from nursing facilities. 

91-017 Evaluation for the Program of All-inclusive 
Care for the Elderly Demonstration 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



500-91-0027 

June 1991 -January 1997 

S 4,486,514 

Contract 

David Kidder, Ph.D. 
Abt Associates, Inc. 
55 Wheeler Street 
Cambridge, MA 02138 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



59 



HCFA Project Elizabeth Mauser, Ph.D. 
Officer: Division of Aging and Disability 

Mandates: Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 
Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 

Description: The Program for All-inclusive Care for the 
Elderly (PACE) Demonstration replicates a unique model 
of managed-care service delivery for 300 very frail 
community-dwelling elderly, most of whom are dually 
eligible for Medicare and Medicaid coverage and all of 
whom are assessed as being eligible for nursing home 
placement according to the standards established by 
participating States. The model of care includes, as core 
services, the provision of adult day health care and 
multidisciplinary team case management through which 
access to and allocation of all health and long-term-care 
services are arranged. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. One purpose of the evaluation is 
to examine PACE sites before and after assumption of full 
financial risk, with the purpose of determining whether 
the PACE model of care, as a replication of the On Lok 
Senior Health Services model of care, is cost-effective 
relative to the existing Medicare and Medicaid programs. 
Another purpose is to examine the decision to enroll in 
PACE in order to understand how PACE enrollees differ 
from those who are eligible for PACE but refuse to enroll 
in the program; to determine the impact of PACE on 
participant health services utilization, expenditures, and 
outcomes; and to explore the subobjectives of PACE or 
the link between PACE and the outcomes of interest. 

Status: This project initiated primary data collection in 
January 1995 that will continue through the end of this 
contract. Reports based on site visits to demonstration 
sites operating under capitated Medicare and Medicaid 
payments have been received annually. Preliminary 
impact results have been received and suggest that: 

• PACE reduces nursing home and hospital use, while 
increasing use of ambulatory and other non- 
institutional services. 

• PACE is associated with improved health status, quality 
of life and satisfaction, though not with measurable 
improvement in physical function;. 

• Although PACE participants survive longer than non- 
participants, the difference is not statistically 
significant. 

• PACE appears to be more effective at reducing 
institutional utilization and improving health status and 
satisfaction for participants with high levels of physical 
impairment than for the less impaired. 



93-050 Examination of Alternative Methods for 
Calculating Relative Values for Practice Expenses: 
University of Minnesota 

Project No.: 500-92-0022DO02 

Period: June 1993-October 1995 

Award: Delivery Order in Master Contract 

Funding: $ 509,740 

Principal 

Investigator: Mark V. Pauly, Ph.D. 

Awardee: University of Minnesota 

(See page 194) 
HCFA Project Edgar A. Peden, Ph.D. 
Officer: Division of Payment Systems 

Description: The purpose of this delivery order is to 
examine alternative methods for determining the practice 
expense components of the relative value scale for the 
Medicare fee schedule. To this end, it first examines two 
alternative measures of procedure costs — econometric cost 
functions and accounting methods. Based on these costs, 
volume and revenue outcomes are examined on a 
procedure and specialty basis under alternative methods of 
fee setting. The current method used to determine practice 
expense relative- values was largely dictated in legislation 
which requires that they be determined for each procedure 
or service by specialty from the historic average charges 
and the practice expense portion of gross revenue. It also 
takes into account the volume shares for each specialty. 
Practice expenses do not include the value of the 
physician's own work related to performing services for 
patients or malpractice insurance expenses. 

The Physician Payment Review Commission and some 
others, including the Harvard Resource-Based Relative- 
Value-Scale study team, have expressed a belief that the 
current method yields irrational results. Others have said 
that the results yield payments which are as inefficient or 
even less efficient than those which arose from the former 
Medicare customary, prevailing, and reasonable physician 
payment system. 

This project is the third in a series done by the Leonard 
Davis Institute of the University of Pennsylvania under a 
subcontract to Minnesota to develop practice-cost pricing 
criteria. The two previous projects are completed and 
reports have been sent to the National Technical 
Information Service; the first discusses various theories of 
pricing ("Allocating Practice Costs: Conceptual Issues," 
accession number, PB92- 172964). The second uses data to 
estimate the effects of different pricing schemes 
("Allocating Practice Costs: Simulations and Other 
Empirical Work"). The unique feature of these three 
projects is that they include a scenario for the efficient 
allocation of physicians' practice expenses as well as the 
conceptually simpler methods which look only at covering 
costs. 



60 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



Status: The work of this project uses and extends the 
methodologies developed in the earlier projects to 
determine practice relative value units on a procedure and 
specialty basis. It used a two-pronged approach. The first 
measured practice costs and the second developed 
efficiency criteria based on Ramsey pricing techniques 
using the practice cost results. With regard to the first, 
practice costs were measured in two ways: 

• An accounting method which the authors report to be a 
promising approach for generating data about the cost 
of a large number of individual physician practices. 

• Econometric cost functions which the authors find yield 
significant insights about physician practice costs. 

The latter work included an innovative approach wherein 
practice costs, in addition to being a function of 
conventional measures such as outputs and input prices, 
were also found in some circumstances to yield a negative 
function of actual to predicted output. But, with regard to 
Ramsey pricing, the authors conclude that its application 
and properties as previously developed can be called into 
question because the predicted positive income- 
compensated elasticities were not observed in their 
empirical work. They suggest that further inquiry into 
welfare issues may be in order. They go oh to note that 
there did appear to be significant behavioral responses to 
relative price changes, which might be further pursued as 
a basis of price strategies for reducing program 
expenditures. The final report has been received and 
accepted. 

93-069 External Assessment of Quality Assurance in 
the Program for All-Inclusive Care for the Elderly 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 

HCFA Project 
Officer: 

Mandates: 



500-92-0014DO02 

September 1993-March 1996 

S 389,218 

Delivery Order in Master Contract 

David Kidder, Ph.D. 
Abt Associates, Inc. 
(See page 64) 
Elizabeth Mauser. Ph.D. 
Division of Aging and Disability 

Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 
Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 



Description: The purpose of this study is to develop and 
test an external quality assurance program for the 
Program for All-inclusive Care for the Elderly (PACE) 
model of care based on structured implicit review. These 



measures may be used by the Health Care Financing 
Administration and State Medicaid agencies in quality 
assurance monitoring of the PACE program. The two key 
approaches that form the basis for the development of a 
quality assurance program are a "tracer approach" that 
identifies certain events whose existence represents a sign 
of unsatisfactory care, and "general patient-centered 
measures" of health outcomes that reflect the total effects 
of care on the individual patient. The quality assurance 
approach encompasses both process and outcome 
elements. 

Status: Tracer conditions have been developed by the 
University of Minnesota, the subcontractor for this 
delivery order. The University of Minnesota has obtained 
copies of medical records from each of the PACE sites 
and has abstracted the necessary information from the 
medical records. Final reports describing the success of 
structured implicit review, information about patient 
satisfaction and the feasibility of conducting this type of 
monitoring system on a group of control patients have 
been submitted. The results suggest cautious optimism 
about using structured implicit review on a wide scale. 
Although this approach can detect differences in patterns 
of care, inter-rater reliability is not high. 

94-112 Implementation and Evaluation of Ambulatory 
Patient Groups as an Outpatient Measurement and 
Financing Methodology in Maine 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-90410/1 

September 1994-December 1996 
$ 263,300 
Cooperative Agreement 

Marianne Ringel 

State of Maine 

State House Station 102 

9 Green Street 

Augusta, ME 04333 

Joseph M. Cramer 

Division of Payment Systems 



Description: The project will establish a comprehensive 
all-payer outpatient database and will implement 
ambulatory patient groups (APGs) as an outpatient 
measurement and financing methodology in Maine. The 
project will develop a comprehensive database for all 
hospital outpatient services that can be used in health care 
policy, planning, research, and regulation. The project 
intends to provide the results of Maine's experience in the 
implementation of APGs and an evaluation of their 
potential to control health care costs. 

Status: Because of Maine legislative changes, a major 
change took place in the project so that APGs will now 
become the basis for the development of hospital 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



61 



outpatient cost, access and quality reports rather than 
being incorporated into the hospital financing system. 
Hospital and ambulatory surgery center data was grouped 
into APGs a second time using more refined data, and a 
second set of weights using all-payer data was computed. 
The development of management report cards using 
APGs also began. A final report is expected in late 1996. 

90-021 Implementation of the Home Health Agency 
Prospective Payment Demonstration 



94-062 Implementation of the Multistats Nursing 
Home Case-Mix and Quality Demonstration 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



500-90-0024 

June 1990-November 1995 

S 1.629,606 

Contract 

Henry Goldberg 
Abt Associates, Inc. 
55 Wheeler Street 
Cambridge, MA 02138 
J. Donald Sherwood 
Division of Payment Systems 

Omnibus Budget Reconciliation Act of 
1987 (Public Law 100-203) 



Description: This contract implements and monitors the 
demonstration design for the Home Health Agency 
Prospective Payment Demonstration, which was 
developed under an earlier contract with Abt Associates, 
Inc. Under this project, two methods of paying home 
health agencies (HHAs) on a prospective basis for services 
furnished under the Medicare program will be tested. The 
prospective payment approaches to be tested include 
payments per visit by type of discipline (Phase I), and 
payments per episode of Medicare-covered home health 
care (Phase II). HHA participation is voluntary. In each 
phase, HHAs that agree to participate are Randomly 
assigned to either the prospective payment method or to a 
control group that continues to be reimbursed in 
accordance with the current Medicare retrospective 
cost system. HHAs participated in the demonstration 
for 3 years. 

Status: Following an initial recruitment of HHAs, 
operations under Phase I were implemented on 
October 1, 1990. Forty-nine HHAs were recruited. All 
agencies under Phase I completed their 3-year 
participation by October 1994. An evaluation of Phase I 
was conducted by Mathematica Policy Research, Inc., 
through a separate contract (see contract 500-90-0047 in 
this edition of Active Projects Report. Recruitment for 
Phase II agencies began in Fall 1994. The implementation 
of Phase II, the per-episode payment phase, will be 
conducted by Abt Associates under a separate contract 
(see identifier 95-076). 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-94-0010 

February 1994-December 1998 

$ 3,209,538 

Contract 

Robert E. Burke, Ph.D. 
Allied Technology Group, Inc. 
1803 Research Boulevard, Suite 601 
Rockville, MD 20850 
Elizabeth S. Cornelius 
Division of Payment Systems 



Description: This contract will support the 
implementation phase of the Multistate Nursing Home 
Case-Mix and Quality Demonstration. The demonstration 
combines the Medicare and Medicaid nursing home 
payments and quality monitoring system across several 
States: Kansas, Maine, Mississippi, New York, South 
Dakota, and Texas. This project builds on past and 
current initiatives with case-mix payment and quality 
assurance in nursing homes. The purpose of the 
demonstration is to test a resident information system 
with variables for classifying residents into homogeneous 
resource utilization groups for equitable payment and for 
quality monitoring of process and outcomes adjusted for 
case mix. The project will have three phases — systems 
design and development, systems implementation and 
monitoring, and evaluation. 

The objectives of the implementation phase are to: 

• Recruit facilities in the six demonstration States to 
participate in the Medicare portion. 

• Develop and operate the Medicare case-mix system of 
the demonstration for the Health Care Financing 
Administration that involves the fiscal intermediaries 
and the Medicare skilled nursing facility (SNF) 
providers. 

• Conduct a staff-time measurement study to validate the 
Resource Utilization Group, Version III (RUG III) 
classification system and add a valid therapy payment 
component. 

• Validate the quality indicators (QIs) and implement the 
quality monitoring system in the demonstration States , 
through the States' nursing home survey process. 

• Implement an administrative management and 
operational system that links distinct components of the 
demonstration (e.g., classification of residents, 
Medicare coverage determination, payment systems, 
outcome monitoring for quality assessment reliability). 

• Implement a field auditing system that monitors States 
and nursing homes participating in the Medicare 
portion. 



62 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



Status: In July 1993, implementation of the Medicaid 
prospective payment systems was begun, with full 
participation in 1994. Kansas, Maine, Mississippi, and 
South Dakota are beginning to routinely use the QI 
reports in the survey and certification process as of 
October 1995, based on the pilot test report and the first 
nine validation visits. 

In Fall 1996, there were more than 2,100 Medicare SNFs 
in the 6 demonstration States, in contrast to 1,120 in 
1 990. There were over 1 ,500 invitations sent to providers 
in October 1996, for Phase III (routine and rehabilitation) 
of the demonstration expressing interest in further 
information by Summer 1995. Phase I operation of the 
Medicare prospective payment system began in July 1995. 
By Fall 1995, there were 300 facilities being paid for 
routine services using the 3 regional multistate Medicare 
payment indices. 

The RUG III validation staff-time measurement data 
collection was completed in seven States by July 1, 1995, 
including the minimum data set 2.0 (MDS2.0) on 2,056 
residents across approximately 80 study units in seven 
States, not counting New York. Data collection in New 
York will be completed in early 1996 and added to the 
validation database. The resident level validation data file 
is currently being compiled. The multiple analyses will be 
carried out during Winter 1995, with the rehabilitation 
(occupational, physical, and speech therapy) index added 
to the Medicare payment system in Spring 1996. 

Phase II of the Medicare portion of the demonstration will 
begin at the start of providers' fiscal years beginning 
January 1, 1996. In January 1996, and each calendar year 
thereafter to the end of the demonstration, the prospective 
rates will be inflated on January 1. Phase III of the 
demonstration, when the rehabilitation therapies will be 
added to the prospective payment, will begin April 1996 
in the fiscal year of the provider. Recruitment of SNF 
participation will end in 1997. 

89-030 Long-Term-Care Case-Mix and 
Quality Technical Design Project 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-89-0046 

September 1989— December 

$ 3,097,982 

Contract 



993 



Robert E. Burke, Ph.D. 

The Circle, Inc. 

8201 Greensboro Drive, Suite 600 

McLean, VA 22102 

Elizabeth S. Cornelius 

Division of Payment System 



Description: This 4-year contract has supported the 
design phase of the multistate Nursing Home Case-Mix 



and Quality (NHCMQ) Demonstration. The demonstration 
combines the Medicare and Medicaid nursing home 
payment and quality monitoring system across several 
States: Kansas, Maine, Mississippi, New York, South 
Dakota, and Texas. This project builds on past and current 
initiatives with case-mix payment and quality assurance in 
nursing homes. The purpose is to test a resident 
information system with variables for classifying residents 
into homogeneous resource-use groups for equitable 
payment and for quality monitoring of process and 
outcomes adjusted for case mix. The project will have 
three phases — systems design and development, systems 
implementation and monitoring, and evaluation. 

Status: The classification system to be used for Medicare 
and Medicaid across the demonstration States was 
completed in June 1991 by researchers from the 
University of Michigan and Rensselaer Polytechnic 
Institute. The Resource Utilization Group, Version III 
(RUG-III), uses 44 groups to explain approximately 
45 percent of the variance in nursing staff time and 
52 percent of the costs across nursing, occupational 
therapy, physical therapy, speech pathology, 
transportation, and social work services. RUG-IIIs are 
split on clinical conditions, including signs and symptoms 
of distress, type and intensity of service, and activities of 
daily living. The 27 groups at the top of the classification 
system closely correlate with the Medicare coverage 
criteria. Five papers covering the analyses done on 
developing the classification system have been published. 
A working paper, "Description of the Resource Utilization 
Group, Version III (RUG-III)," which describes the 
classification, is available from the Office of Research and 
Demonstrations, HCFA. The common assessment tool, 
the minimum data set plus (MDS+), has been developed 
and implemented as the State resident assessment 
instrument in the demonstration States. A training 
manual that includes the MDS+ and the resident 
assessment protocols has been published: Feldman, J., and 
Boulter, C, eds.: Minimum Data Set Plus (MDS+). 
Multistate Nursing Home Case-Mix and Quality 
Demonstration Training Manual. Natick, MA. Eliot 
Press, 1991. Four Medicaid systems have been 
implemented at the present time. The analysis of 1990 
Medicare Cost Reports and 1990 case-mix data to develop 
the Medicare payment design are completed. A working 
paper, "Issue Paper on Development of Medicare SNF 
Payment Rates," was developed and distributed to persons 
working on the payment system design. The Medicare 
payment system portion of the demonstration was 
implemented in July 1995 under a separate contract. 
Under a subcontract with The Circle, the University of 
Wisconsin's researchers developed a preliminary list of 
3 1 facility-level quality indicators (QIs) that were used in 
a four-State pilot test. They were reviewed by expert 
surveyors from the 6 States, a research-oriented quality 
panel, and a clinical work group of 60 health professionals 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



63 



representing about 15 disciplines working in long-term 
care. A paper describing the analyses done and issues 
addressed in developing the QIs was published in the 
Summer 1 995 issue of the Health Care Financing Review. 
The QIs will serve to enhance the quality assurance 
process to be used for the operational phase. The final set 
of QIs will be implemented throughout the demonstration 
in 1995. The final report of the technical design phase of 
the multistate NHCMQ Demonstration, including 
appendixes, has been received, accepted. The products of 
the design phase include several software programs: 

• A modified 1.01 version of Malitz, D., Ph.D., and 
Godbout, R. C, Ph.D.: PC Group: "A Statistical 
Package Software for Interactive Data Exploration and 
Model Building for Cluster Analysis Tested," revised in 
1990 and an updated 3.01 to Group PC Version, revised 
in 1992 — available from Austin Data Management 
Associates, Post Office Box 4358, Austin, Texas 
78765, telephone number (512) 320-0935. 

• The Grouper, Classification Algorithm for RUG III 
using the MDS+,1992. 

• M3PI Processor, Classification Software for RUG III 
and M3PI using the MDS+. 

• MDS+ Analytic Database and Management Software, 
1993. 

• An RSM/STM Research Database, 1991, developed 
from the Resident Status Measure and Staff Time 
Measurement (RSM/STM) Study in seven States. 

• Clinical Profiles of RMS/STM Study Population in 
EXCEL. 

• RUG III Grouping Algorithm using, Medicare provider 
analysis and review (MEDPAR), 1993. 

94-110 Maine Medicare Volume Performance 
Standard Demonstration Project 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



19-C-90401/1 

September 1 994-November 1997 
$ 341,750 
Cooperative Agreement 

Robert B. Keller, M.D. 

Maine Medical Assessment Foundation 

P. O. Box 4682 

Augusta, ME 04330-1682 

Mark A. Krause, Ph.D. 

Division of Payment Systems 



Description: This research was to assess the feasibility 
and value of a State-level Medicare volume performance 
standard (MVPS). Among other individuals, analysts at 
the Physician Payment Review Commission have raised 
questions regarding the effectiveness of the current 
national volume performance standard methodology. 



These analysts have argued that the current MVPS 
program may not be accomplishing its intended goal of 
providing an incentive for physicians to avoid excessive 
increases in the volume of services they furnish to 
Medicare beneficiaries. The Maine Medical Assessment 
Foundation (MMAF) in conjunction with the Urban 
Institute undertook to analyze national and State-level 
physician data to provide information about the volume 
(rate) and intensity (relative value units) of medical 
services provided to Medicare beneficiaries in the State of 
Maine. MMAF will utilize these data to create analytic 
files and reports on population-based utilization rates of 
services and the intensity of those services. Data was 
provided to 10 specialty study groups. This information 
was used by physicians to change their practice behaviors 
by improving the efficiency and appropriateness of the 
care they provide. Access and quality of care was 
monitored closely by an advisory committee, and all 
aspects and implications of the project were evaluated by 
the project staff and an external reviewer. 

Status: The project has been discontinued. Although 
MMAF was successful in developing profiling methods 
and ways to effectively share them with practicing 
physicians, no effective progress was made in developing 
a State-level approach to the MVPS. A letter type final 
report has been received that outlines the activities 
conducted under this agreement. 

92-081 Medicare Ambulatory and Coordinated 
Care Demonstration Projects: Master Contract: 
Abt Associates, Inc. (Formerly, Medicare Ambulatory 
and Coordinated Care Demonstration Projects: 
Master Contracts) 

Project No.: 500-92-0014 

Period: July 1992-September 1997 

Award: Contract 

Principal 

Investigator: David Kidder, Ph.D. 

Awardee: Abt Associates, Inc. 

55 Wheeler Street 
Cambridge, MA 02138-1 168 

HCFA Project Samuel L. Brown 

Office: Division of Aging and Disability 

Description: This master contract provides for the design, 
development, conduct, and evaluation of Medicare 
ambulatory and coordinated care demonstration projects. 
The intent of these demonstration projects is to obtain 
information in a timely manner for program and policy 
consideration. 

Status: This master contract was awarded in July 1992. 
This awardee is able to compete for individual delivery 



64 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



orders (DO) for 36 months. The first DO (awarded 
concurrently with the base contract) is for general 
management, which includes monthly Federal reports, 
meeting with the Federal Government on request, and 
responding to requests for issue papers. The funding 
amount for the first DO, 500-92-00 14DO01, management 
delivery order, is $33,137. The individual DO projects 
awarded under the master contract are described in detail 
in the following sections of this edition of Active Projects 
Report. 

Theme 1: Monitoring and Evaluating Health 
Systems Performance: Access, Quality, Program 
Efficiency and Costs 

• Community Nursing Organization Demonstration 
External Quality Assurance, 500-92-00 14DO04. 

• Evaluation of the Effectiveness of the Operation Restore 
Trust Demonstration, 500-92-00 14DO06. 

Theme 2: Improving Health Care Financing and 
Delivery Mechanisms: Current Programs and 
New Models 

• External Assessment of Quality Assurance in the 
Program of All-inclusive Care for the Elderly, 
500-92-0014DO02. 

• Medicare Competitive Pricing Demonstration, 
500-92-0014DO05. 

92-080 Medicare Ambulatory and Coordinated Care 
Demonstration Projects: Master Contract: Health 
Economics Research, Inc. (Formerly, Medicare 
Ambulatory and Coordinated Care Demonstration 
Projects: Master Contracts) 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-92-0013 

July 1992-September 1997 

Contract 

Jerry Cromwell, Ph.D. 

Health Economics Research, Inc. 

300 Fifth Avenue, 6th Floor 

Waltham, MA 02154 

Samuel L. Brown 

Division of Aging and Disability 



Description: This master contract provides for the design, 
development, conduct, and evaluation of Medicare 
ambulatory and coordinated care demonstration projects. 
The intent of these demonstration projects is to obtain 
information in a timely manner for program and policy 
consideration. 

Status: This master contract was awarded in July 1992. 
This awardee is able to compete for individual delivery 
orders (DO) for 36 months. The first DO (awarded 
concurrently with the base contract) is for general 



management, which includes monthly funding reports, 
meeting with the Federal Government on request, and 
responding to requests for issue papers. The funding 
amount for the first DO, 500-92-0013DO01, management 
delivery order, is $ 53,898. The individual DO projects 
awarded under the master contract are described in detail 
in the following section of this edition of Active Projects 
Report. 

Theme 2: Improving Health Care Financing and 
Delivery Mechanisms: Current Programs and 
New Models 

• Medicare Negotiated Bundled Payment 
Demonstrations: Design and Solicitation, 
500-92-00 13DO04. 

• Medicare Participating Heart Bypass Center 
Demonstration Extended Evaluation, 
500-92-00 13DO03. 

• Per Case Payment to Encourage Risk Management and 
Service Integration in the Inpatient Acute Care Setting, 
500-92-00 13DO05. 

92-078 Medicare Ambulatory and Coordinated Care 
Demonstration Projects: Master Contract: 
Mathematica Policy Research, Inc. (Formerly, Medicare 
Ambulatory and Coordinated Care Demonstration 
Projects: Master Contracts) 

Project No.: 500-92-0011 

Period: July 1992-June 1998 

Award: Contract 

Principal 

Investigator: Randall S. Brown, Ph.D. 

Awardee: Mathematica Policy Research, Inc. 

P. O. Box 2393 

Princeton, NJ 08543-2393 
HCFA Project Samuel L. Brown 
Officer: Division of Aging and Disability 

Description: This master contract provides for the design, 
development, conduct, and evaluation of Medicare 
ambulatory and coordinated care demonstration projects. 
The intent of these demonstration projects is to obtain 
information in a timely manner for program and policy 
consideration. 

Status: This master contract was awarded in July 1992. 
This awardee is able to compete for individual delivery 
orders (DO) for 36 months. The first DO (awarded 
concurrently with the base contract) is for general 
management, which includes monthly reports, meeting 
with the Federal Government on request, and responding 
to requests for issue papers. The funding amount for the 
first DO, 500-92-001 1DO01, management delivery order, 
is $ 34,95 1 . The individual DO projects awarded under 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



65 



the master contract are described in detail in the following 
section of this edition of Active Projects Report. 

Theme 2: Improving Health Care Financing and 
Deliver}' Mechanisms: Current Programs and 
New Models 

• Evaluation of the Cost of Health Maintenance 
Organizations and Health Care Prepayment Plans, 
500-92-001 1DO03. 

• Evaluation of the Medicare Case Management 
Demonstrations, 500-92-001 1DO02. 

• Evaluation of Medicare Choice Demonstration, 
500-92-001 1DO06. 

• Medicare-Preferred Provider Organization, 
500-92-001 1DO05. 

• Physician Capitation for Medicare Services: Feasibility 
Study and Demonstration Design, 500-92-001 1DO04. 

95-017 Medicare Competitive Pricing Demonstrations 

Project No.: 500-92-00 14DO05 

Period: September 1995-September 1997 

Funding: $ 963,550 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Robert Coulam, Ph.D., J.D. 

Awardee: Abt Associates, Inc. 

(See page 64) 
HCFA Project Ronald W. Deacon, Ph.D. 
Officer: Division of Delivery Systems and 

Financing 

Description: Abt Associates, Inc. and its subcontractor, 
University of Minnesota, will assist the Health Care 
Financing Administration (HCFA) in the design, 
development, and implementation of Medicare 
competitive pricing demonstrations. In these 
demonstrations, HCFA will replace the existing fee-for- 
service-based health-maintenance-organization (HMO) 
payment system with a market-based pricing system. All 
competing Medicare HMOs in designated metropolitan 
statistical areas will be asked to bid a capitation price that 
is required to provide a standard benefit package. The 
package will represent the range of benefits currently 
being offered in the area. HCFA will array the bids, select 
a payment level, and pay all HMOs this government 
contribution. Payments will be adjusted to reflect enrollee 
risk characteristics. HMOs which bid higher than the 
government contribution will be required to charge 
premiums which reflect the additional cost. During a 
coordinated open-enrollment period, all Medicare 
beneficiaries in the demonstration areas will receive 
enhanced education and information about the various 
HMO options available, as well as fee-for-service options. 
Beneficiaries will be able to compare premiums, benefits, 
and other HMO characteristics and will be able to enroll 
in the HMO of their choice through an open enrollment 



contractor. Beneficiaries may remain in the fee-for-service 

system. 

Status: The contractor and HCFA developed criteria for 
demonstration site selection and a design report 
describing all aspects of the competitive pricing system. 
Technical expert panels were convened during the year to 
review design work and make recommendations for 
implementing the demonstrations. During 1997, HCFA is 
expected to initiate competitive pricing demonstrations in 
three geographic areas. 

93-084 Medicare-Designated Cataract Surgery 
Providers: Cataract Eye Center of Cleveland, Inc. 

(Formerly, Medicare Designated Cataract Surgery 
Providers) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



95-P-30005/5 
January 1993-April 
Waiver only 
Grant 



1996 



Samuel M. Salamon, M.D. 

Cataract Eye Center of Cleveland, Inc. 

2322 East 22nd Street, Suite 307 

Cleveland, OH 44115 

Cynthia K. Mason 

Division of Delivery Systems and 

Financing 



Description: This physician-group practice in Ohio is one 
of four sites of the demonstration begun by the Office of 
Research and Demonstrations to assess the feasibility of a 
negotiated all-inclusive price concept for cataract surgery. 
The negotiated price covering physician, facility, and 
intraocular lens costs for the procedure is being tested in 
three metropolitan statistical areas: Cleveland, Ohio; 
Dallas/Fort Worth, Texas; and Phoenix, Arizona. 
Participation by providers and beneficiaries at each site is 
completely voluntary. 

Status: In April 1993, the site successfully implemented 
the 3-year demonstration and completed it in April 1996. 

93-081 Medicare-Designated Cataract Surgery 
Providers: National Medical Enterprises (Formerly, 
Medicare Designated Cataract Surgery Providers) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



95-P-30001/6 

January 1993-March 1996 

Waiver-only 

Grant 

Reynold J. Jennings 
National Medical Enterprises 
Doctors Hospital of Dallas 
9440 Poppy Drive 
Dallas, TX 75218 



66 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



HCFA Project Cynthia K. Mason 
Officer: Division of Delivery Systems and 

Financing 

Description: This hospital in Texas is one of four sites of 
the demonstration begun by the Office of Research and 
Demonstrations to assess the feasibility of a negotiated 
all-inclusive price concept for cataract surgery. The 
negotiated price covering physician, facility, and 
intraocular lens costs for the procedure is being tested in 
three metropolitan statistical areas: Cleveland, Ohio; 
Dallas/Fort Worth, Texas; and Phoenix, Arizona. 
Participation by providers and beneficiaries at each site is 
completely voluntary. 

Status: In April 1993, the site successfully implemented 
the 3-year demonstration and completed it in March 1996. 

93-083 Medicare-Designated Cataract Surgery 
Providers: Southwestern Eye Center, Ltd. (Formerly, 
Medicare Designated Cataract Surgery Providers) 



Award: 
Principal 
Investigator: 
Awardee: 



Delivery Order in Master Contract 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



95-P-30003/9 

January 1993-April 1996 

Waiver only 

Grant 

L. Lothaire Bluth, M.D. 

Southwestern Eye Center, Ltd. 

1818 East Southern Avenue, Suite li 

Mesa, AZ 85204 

Cynthia K. Mason 

Division of Delivery Systems and 

Financing 



Description: This ambulatory surgery center in Arizona is 
one of four sites of the demonstration begun by the Office 
of Research and Demonstrations to assess the feasibility of 
a negotiated all-inclusive price concept for cataract 
surgery. The negotiated price covering physician, facility, 
and intraocular lens costs for the procedure is being tested 
in three metropolitan statistical areas: Cleveland, Ohio; 
Dallas/Fort Worth, Texas; and Phoenix, Arizona. 
Participation by providers and beneficiaries at each site is 
completely voluntary. 

Status: In April 1993, this site successfully implemented 
the 3-year demonstration and completed it in April 1996. 

94-103 Medicare End Stage Renal Disease (ESRD) 
Capitation Demonstration: Technical Assistance 
Contract 

Project No.: 500-94-0043DO02 

Period: September 1 994-September 1997 

Funding: $ 499,444 



Stanley Wallack, Ph.D. 

Brandeis University 

Heller Graduate School 

Institute for Health Policy 

415 South Street 

P. O. Box 91 10 

Waltham, MA 02254-9110 
HCFA Project Bonnie M. Edington 
Officer: Division of Health Information and 

Outcomes 

Description: The Omnibus Budget Reconciliation Act of 
1993 extended the social health maintenance organization 
(SHMO) demonstrations and authorized an end stage 
renal disease (ESRD) SHMO demonstration. The purpose 
of this contract is to assist the Health Care Financing 
Administration (HCFA) in developing and implementing 
the ESRD Managed-Care Demonstration authorized 
through that legislation. The contractor also has a 
subcontract with Boston University for these purposes. 
A separate procurement action will award a contract to 
evaluate the demonstration. 

Under the technical assistance contract, an announcement 
of the demonstration was sent to all dialysis and kidney 
transplant facilities, all health maintenance organizations 
with a Medicare contract, and all insurance companies 
with a Medicare contract, in October 1995. The Federal 
Register Notice for the ESRD Managed-Care 
Demonstration was published January 26, 1996, the 
Request for Proposal (RFP) was mailed to all requesters 
on February 29, and proposals were received by May 17. 

Status: Awards were made September 24 to four 
organizations: Health Options in Florida; Kaiser 
Foundation Health Plan, Southern California; PacifiCare 
of California; and Phoenix Healthcare of Tennessee. The 
contractor will work with HCFA in making site visits and 
providing technical assistance to the sites during the 
1-year planning and development phase, before service 
delivery begins. The contractor will also be responsible 
for providing information to HCFA for the development 
of an interim Report to Congress. 

95-050 Medicare Negotiated Bundled Payment 
Demonstrations: Design and Solicitation 

Project No.: 500-92-00 13TO04 

Period: July 1995-June 1997 

Funding: $ 365,502 

Award: Task Order in a Basic Order Contract 

Technical Support: Design and 

Solicitation 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



67 



Principal 

Investigator: Jerry Cromwell. Ph.D. 

Awardee: Health Economics Research, Inc. 

(See page 65) 
HCFA Project Armen H. Thoumaian, Ph.D. 
Officer: Division of Delivery Systems and 

Financing 

Description: The awardee will assist the Health Care 
Financing Administration (HCFA) in preparing the 
design and solicitation of a 3-year demonstration to test 
the feasibility of a negotiated all-inclusive pricing 
arrangement for a group of cardiovascular procedures and 
total joint replacement procedures at high-volume 
hospitals in targeted geographic areas. The awardee will 
assist HCFA in the formulation of the design, 
identification of factors for the selection of demonstration 
sites, development and publication of a solicitation 
package, and the analysis and review of respondent 
proposals. 

Status: The geographic analysis was completed with 
recommendations for specific metropolitan statistical 
areas and multistate regions in which to target the 
demonstration solicitation. Preliminary drafts of the 
design and solicitation documentation were submitted for 
a mailing of a preapplication solicitation in December 
1995. Preapplicants recommended by a review panel will 
be invited to submit final applications. Panel review of 
final applications should be completed by May 1997. 

91-006 Medicare Participating Heart Bypass Center 
Demonstration: Georgia 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



95-P-99602/4 

January 1991— December 

Waiver only 

Grant 



996 



Susan White 

Saint Joseph's Hospital of Atlanta 

5665 Peachtree Dunwoody Road, NE. 

Atlanta, GA 30342-1701 

Armen H. Thoumaian, Ph.D. 

Division of Delivery Systems and 

Financing 



Description: This hospital in Georgia is one of seven sites 
of the demonstration begun by the Office of Research and 
Demonstrations to assess the feasibility of a negotiated 
all-inclusive pricing arrangement for coronary artery 
bypass graft (CABG) procedures while maintaining high- 
quality care. Hospitals and physicians participating in the 
project receive a global payment covering hospital and 
related physician services for CABG surgery. 
Participation in the demonstration is completely voluntary 
for Medicare beneficiaries. Hospitals and physicians not 



participating in the demonstration will continue to 
provide services and receive payment under Medicare's 
conventional payment method. 

Status: This hospital, successfully ending its 3-year 
participation in Spring 1994, requested and received a 
2-year continuation under the demonstration until 
June 30, 1996. Hospitals under this demonstration were 
allowed to submit pre-applications for a new 
demonstration, the Participating Centers of Excellence 
demonstration for cardiovascular services. This hospital 
was allowed to continue under the bundled payment 
methodology for heart bypass surgery until December 3 1 , 
1996 or until a determination is made as to whether it will 
be selected for the new demonstration. 

93-011 Medicare Participating Heart Bypass Center 
Demonstration: Indiana 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



95-P-99599/5 

January 1993— December 1996 

Waiver only 

Grant 

Stephen J. Jay, M.D. 

Methodist Hospital of Indiana, Inc. 

1701 North Senate Boulevard 

Indianapolis, IN 46206-1367 

Armen H. Thoumaian, Ph.D. 

Division of Delivery Systems and 

Financing 



Description: This hospital in Indiana is one of seven sites 
of the demonstration begun by the Office of Research and 
Demonstrations to assess the feasibility of a negotiated 
all-inclusive pricing arrangement for coronary artery 
bypass graft (CABG) procedures while maintaining high- 
quality care. Hospitals and physicians participating in the 
project receive a global payment covering hospital and 
related physician services for CABG surgery. 
Participation in the demonstration is completely voluntary 
for Medicare beneficiaries. Hospitals and physicians not 
participating in the demonstration will continue to 
provide services and receive payment under Medicare's 
conventional payment method. 

Status: This hospital successfully implemented the 3-year 
demonstration in Spring 1993. Hospitals under this 
demonstration were allowed to submit pre-applications for 
a new demonstration, the Participating Centers of 
Excellence demonstration for cardiovascular services. 
This hospital was allowed to continue under the bundled 
payment methodology for heart bypass surgery until 
December 31, 1996 or until a determination is made as to 
whether it will be selected for the new demonstration. 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



91-003 Medicare Participating Heart Bypass Center 
Demonstration: Massachusetts 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



95-P-99592/1 

January 1991-December 1996 

Waiver only 

Grant 

Paul Drew 
University Hospital 
Boston University Medical Center 
88 East Newton Street 
Boston, MA 02118-2393 
Armen H. Thoumaian, Ph.D. 
Division of Delivery Systems and 
Financing 



Description: This hospital in Massachusetts is one of 
seven sites of the demonstration begun by the Office of 
Research and Demonstrations to assess the feasibility of a 
negotiated all-inclusive pricing arrangement for coronary 
artery bypass graft (CABG) procedures while maintaining 
high- quality care. Hospitals and physicians participating 
in the project receive a global payment covering hospital 
and related physician services for CABG surgery. 
Participation in the demonstration is completely voluntary 
for Medicare beneficiaries. Hospitals and physicians not 
participating in the demonstration will continue to 
provide services and receive payment under Medicare's 
conventional payment method. 

Status: This hospital, successfully ending its 3-year 
participation in Spring 1994, requested and received a 
2-year continuation under the demonstration until 
June 30, 1996. Hospitals under this demonstration were 
allowed to submit pre-applications for a new 
demonstration, the Participating Centers of Excellence 
demonstration for cardiovascular services. This hospital 
was allowed to continue under the bundled payment 
methodology for heart bypass surgery until December 31, 
1996 or until a determination is made as to whether it will 
be selected for the new demonstration. 

91-004 Medicare Participating Heart Bypass Center 
Demonstration: Michigan 



HCFA Project Armen H. Thoumaian, Ph.D. 
Officer: Division of Delivery Systems and 

Financing 

Description: This hospital in Michigan is one of seven 
sites of the demonstration begun by the Office of Research 
and Demonstrations to assess the feasibility of a 
negotiated all-inclusive pricing arrangement for coronary 
artery bypass graft (CABG) procedures while maintaining 
high-quality care. Hospitals and physicians participating 
in the project receive a global payment covering hospital 
and related physician services for CABG surgery. 
Participation in the demonstration is completely voluntary 
for Medicare beneficiaries. Hospitals and physicians not 
participating in the demonstration will continue to 
provide services and receive payment under Medicare's 
conventional payment method. 

Status: This hospital, successfully ending its 3-year 
participation in Spring 1994, requested and received a 
2-year continuation under the demonstration until 
June 30, 1996. Hospitals under this demonstration were 
allowed to submit pre-applications for a new 
demonstration, the Participating Centers of Excellence 
demonstration for cardiovascular services. This hospital 
was allowed to continue under the bundled payment 
methodology for heart bypass surgery until December 31, 
1996 or until a determination is made as to whether it will 
be selected for the new demonstration. 

91-005 Medicare Participating Heart Bypass Center 
Demonstration: Ohio 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



95-P-99597/5 

January 1991— December 1996 

Waiver only 

Grant 

Kamilla K. Sigafoos 

Ohio State University Hospitals 

450 West 10th Avenue 

Columbus, OH 43210-1228 

Armen H. Thoumaian, Ph.D. 

Division of Delivery Systems and 

Financing 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



95-P-99591/5 

January 1991-December 1996 

Waiver only 

Grant 

Richard Prager, M.D. 
St. Joseph Mercy Hospital 
Catherine McAuley Health System 
5301 East Huron River Drive 
Ann Arbor, MI 48106 



Description: This hospital in Ohio is one of seven sites of 
the demonstration begun by the Office of Research and 
Demonstrations to assess the feasibility of a negotiated 
all-inclusive pricing arrangement for coronary artery 
bypass graft (CABG) procedures while maintaining high- 
quality care. Hospitals and physicians participating in the 
project receive a global payment covering hospital and 
related physician services for CABG surgery. 
Participation in the demonstration is completely voluntary 
for Medicare beneficiaries. Hospitals and physicians not 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



69 



participating in the demonstration will continue to 
provide services and receive payment under Medicare's 
conventional payment method. 

Status: This hospital, successfully ending its 3-year 
participation in Spring 1994, requested and received a 
2-year continuation under the demonstration until 
June 30. 1996. Hospitals under this demonstration were 
allowed to submit pre-applications for a new 
demonstration, the Participating Centers of Excellence 
demonstration for cardiovascular services. This hospital 
was allowed to continue under the bundled payment 
methodology for heart bypass surgery until December 31, 
1996 or until a determination is made as to whether it wil 
be selected for the new demonstration. 

93-012 Medicare Participating Heart Bypass Center 
Demonstration: Texas 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



95-P-99603/6 

January 1993-June 1996 

Waiver only 

Grant 

Michael D. Israel 

St. Luke's Episcopal Hospital 

Texas Medical Center 

6720 Bertner Street 

Houston, TX 77030 

Armen H. Thoumaian, Ph.D. 

Division of Delivery Systems and 

Financing 



Description: This hospital in Texas is one of seven sites of 
the demonstration begun by the Office of Research and 
Demonstrations to assess the feasibility of a negotiated 
all-inclusive pricing arrangement for coronary artery 
bypass graft (CABG) procedures while maintaining high- 
quality care. Hospitals and physicians participating in the 
project receive a global payment covering hospital and 
related physician services for CABG surgery. 
Participation in the demonstration is completely voluntary 
for Medicare beneficiaries. Hospitals and physicians not 
participating in the demonstration will continue to 
provide services and receive payment under Medicare's 
conventional payment method. 

Status: This hospital successfully implemented the 3-year 
demonstration in Spring 1993. Hospitals under this 
demonstration were allowed to submit pre-applications for 
a new demonstration, the Participating Centers of 
Excellence demonstration for cardiovascular services. 
This hospital was allowed to continue under the bundled 
payment methodology for heart bypass surgery until 
December 31, 1996 or until a determination is made as to 
whether it will be selected for the new demonstration. 



94-010 Medicare Participating Heart Bypass Center 
Demonstration Extended Evaluation 

Project No. : 500-92-00 1 3DO03 

Period: July 1994-February 1997 

Funding: $363,318 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Jerry Cromwell, Ph.D. 

Awardee: Health Economics Research, Inc. 

(See pages 65) 
HCFA Project Armen H. Thoumaian, Ph.D. 
Officer: Division of Delivery Systems and 

Financing 

Description: The awardee's objective is to assist the 
Health Care Financing Administration (HCFA) in the 
continued evaluation of a 5-year extended demonstration 
designed to assess the feasibility of a negotiated all- 
inclusive pricing arrangement for coronary artery bypass 
graft surgery while maintaining high quality care. Health 
Economics Research, Inc. (HERI) will assist HCFA by 
continuing the demonstration evaluation plan established 
under a previous contract, by monitoring the 
demonstration sites, by collecting and analyzing data, and 
by preparing the final evaluation report. Some key 
questions to be addressed during the evaluation are: 

• Did the demonstration result in a net cost savings to the 
Medicare program? 

• What was the source of any volume increases at the 
demonstration sites? 

• What aspects of a demonstration site are attractive to 
Medicare beneficiaries and to referring physicians? 

• Was the quality of care at the demonstration sites 
equivalent to that provided at the sites prior to the 
demonstration? 

Status: HCFA negotiated with the finalists and selected 
four demonstration sites in January 1991. Implemen- 
tation of the demonstration at three sites began in 
May 1991. In December 1992, HCFA expanded the 
demonstration to include three additional sites from 
among the remaining six recommended hospitals, 
bringing the total number of demonstration sites to seven. 
These additional sites began service delivery under the 
demonstration in May and June 1993. In Spring 1994, at 
their request, the first four sites were allowed to continue 
under the demonstration for an additional 2 years. In 
June 1994, a new evaluation contract was awarded to 
HERI to extend the evaluation of the seven sites for the 
remainder of their participation. The final evaluation 
report is expected in February 1997. 



70 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



94-011 Medicare Preferred Provider Organization 

(Medicare Choices Demonstration) 

Project No.: 500-92-001 1DO05 

Period: July 1 994-December 1996 

Funding: S 560,040 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Merrile Sing, Ph.D. 

Awardee: Mathematica Policy Research, Inc. 

(See page 65) 
HCFA Project Victor G. McVicker 
Officer: Division of Delivery Systems and 

Financing 

Description: Mathematica Policy Research, Inc. (MPR) is 
to assist the Health Care Financing Administration 
(HCFA) in the design and implementation of the 
Medicare Choices Demonstration. MPR will work with 
HCFA to develop guidelines for plan participation in the 
demonstration, recruit potential demonstration sites, and 
assist HCFA with demonstration implementation 
activities. The purpose of this demonstration is to test the 
receptivity of Medicare beneficiaries to a broad range of 
managed-care delivery system options and to evaluate the 
suitability of such options for the Medicare program. This 
demonstration will also provide a head start on 
developing solutions to a wide range of implementation 
issues (such as risk sharing, payment methods, 
certification requirements, and quality monitoring 
systems) which would be associated with some legislative 
expansions of Medicare managed care currently under 
consideration. The solicitation for proposals will be 
conducted in two stages. In the first stage, information 
about the demonstration will be provided to managed-care 
plans and provider groups through direct mail and by 
contracting large employer and health trade organizations 
such as the Group Health Association of America and the 
Managed-Care Review Association. 

Interested organizations will be asked to complete a 
preapplication form. HCFA will target nine market areas 
to contact and recruit individual organizations for the 
demonstration, but will also consider innovative proposals 
from other parts of the country. The returned 
preapplication forms will be screened, and selected 
organizations will be invited to complete and submit a 
second, more complete application within a 2-month 
period. The demonstration sites will be selected based on 
a review of these applications with an award expected in 
late 1996. The demonstration will run 3 to 5 years. 

Status: HCFA received 372 preapplications. representing 
nearly every State in the Nation. From the 372 pre- 
applications, HCFA invited 52 managed-care plans to 
submit final applications to HCFA by December 15, 1995. 
In response, HCFA received 37 proposals. 



Based on geographic factors, innovation of design, and 
ability to meet eligibility requirements, HCFA selected 
25 "award candidates" for final consideration — nine 
provider sponsored organizations, eight provider-owned 
health maintenance organizations (HMOs) or providers 
with HMO partners, and eight HMOs or other managed- 
care organizations. Actual awards will be contingent upon 
each plan's successful completion of negotiations with the 
Office of Research and Demonstrations and certification 
by the Office of Managed Care. 

The selected sites are in the final stages of the award 
process. All of the applicants' documentation has been 
reviewed for completeness and is being augmented by the 
plans where deemed necessary. Several of the sites have 
completed negotiations, and site visits are under way. 
Most of the State licensure issues have been resolved. For 
the few remaining, resolution is expected in late 1996. 

94-066 Midwest Rural Telemedicine Consortium: 
A Pilot Demonstration Project 

Project No.: 95-C-90425/7 

Period: July 1994-September 1997 

Funding: S 3,229,236 

Award: Grant 

Principal 

Investigator: Harrison Pratt, D.O. 

Awardee: Mercy Foundation 

Sixth and University 

Des Moines, IA 50314 
HCFA Project Lawrence E. Kucken 
Officer: Division of Health Information and 

Outcomes 

Description: This project is evaluating the medical 
effectiveness, patient and provider acceptance, and costs 
associated with telemedicine services, as well as their 
impact on access to care in rural areas. The demonstration 
involves 10 rural hospitals, 1 rural referral hospital, and 
1 urban hospital. Planned services for the demonstration 
include interactive video consults for teleradiology, 
telepathology, and, where available, telesonography, 
electrocardiography, and fetal monitoring strips. Payment 
for related physician services is expected to be made 
under a waiver of Medicare payment regulations. The 
goal of the project is to evaluate whether specialty 
telemedicine services provided by hospital networks 
produce change with respect to medical effectiveness, 
patient and provider satisfaction, cost, and access. 
Hypotheses include telemedicine improving differential 
diagnoses and treatment; patients and providers being as 
satisfied with telemedicine as with on site services; 
telemedicine services being less costly than on site 
services; and telemedicine improving access to a wider 
range of health care services. 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



71 



Status: This telemedicine network has been implemented. 
A Medicare waiver to permit payment to providers 
participating in the project was recently approved. No 
data is available at this time. 

96-046 Mississippi New Direction Welfare Reform 
Demonstration Project: Amendment 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-0007 1/4-01 

October 1 995-October 200 1 
Waiver-only 

Donald R. Taylor 

Department of Human Services 

750 North State Street 

Jackson, MS 39202 

Maria Boulmetis 

Office of State Health Reform 

Demonstrations 



Description: The project was implemented on 
October 1, 1995 with waivers from the Administration 
For Children and Families. In November 1995, the State 
submitted an amendment to the demonstration to ease the 
requirements to obtain Medicaid transitional benefits and 
apply the same sanctions to voluntary Jobs Opportunity 
and Basic Skills (JOBS) participants that apply to 
mandatory JOBS participants. 

Status:The State continues to implement the 
demonstration. With the August 22, 1996 enactment of 
the Personal Responsibility and Work Opportunity 
Reconciliation Act of 1996 (PRWORA), it is anticipated 
that the Title IV-A component of this demonstration will 
be modified. However, the impact of the PRWORA is 
being analyzed. 

94-130 Monitoring and Evaluation of the Medicare 
Cataract Surgery Alternate Payment Demonstration 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator 

Awardee: 



500-94-0038 
August 1994-March 
$ 496,049 
Contract 



997 



Leo Reardon 

Abt Associates, Inc. 

55 Wheeler Street 

Cambridge, MA 02138 
HCFA Project Cynthia K. Mason 
Officer: Division Delivery Systems and Financing 

Description: The objective of this contract is to assist the 
Health Care Financing Administration in the monitoring 
and evaluation of a demonstration to assess the feasibility 
of an all-inclusive negotiated price concept for cataract 
surgery. The negotiated price covering physician, facility, 



and intraocular lens costs for the procedure have been 
tested at a total of four sites in three metropolitan 
statistical areas. The 3-year demonstration was completed 
in April 1996. Participation by providers and beneficiaries 
at each site was completely voluntary. Some key questions 
to be addressed during the evaluation are: 

• Did the demonstration result in a net cost savings to the 
Medicare program? 

• What is the change over time in the use of services 
included and the use of services excluded from the 
bundle? 

• Did the quality of care at the demonstration sites 
change from the care provided at the same sites prior to 
the demonstration? 

Status: An interim report based on the first year's data 
was completed in late Spring 1996. The final report is 
expected in late Spring 1997. 

89-054 Multistate Nursing Home Case-Mix and 
Quality Demonstration: Kansas (Formerly, The 
Multistate Nursing Home Case-Mix and Quality 
Demonstration) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-C-99366/7 
June 1989-December 1998 
$ 1,544,755 
Cooperative Agreement 

Elaine Wells 

Kansas Department of Social and 

Rehabilitative Services Adult Services 

Commission-Adult Care Home Program 

West Hall 

300 Oakley Street, SW. 

Topeka, KS 66606 

Elizabeth S. Cornelius 

Division of Payment Systems 



Description: This project builds on past and current 
initiatives with nursing home case-mix payment and 
quality assurance. The 6-year demonstration will design, 
implement, and evaluate a combined Medicare and 
Medicaid nursing home resident classification and 
payment system in Kansas, Maine, Mississippi, and South 
Dakota. The purpose of the demonstration is to test a 
resident information system with variables for classifying 
residents into homogeneous resource use groups for 
equitable payment and for quality monitoring of outcomes 
adjusted for case mix. The new minimum data set plus 
(MDS+) for resident assessment will be used for resident- 
care planning, payment classification, and quality- 
monitoring systems. The project consists of three phases: 
systems development and design, systems implementation 
and monitoring, and evaluation. 



72 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



Status: The project has conducted a field test of the 
minimum data set on 6,660 nursing home residents. The 
average direct-care staff time across the States is 
115 minutes per day per resident. A new patient 
classification system and a Multistate Medicare/ Medicaid 
Payment Index containing 44 groups has been created. 
Kansas uses all 44 groups and the nursing plus therapy 
index in its Medicaid system. States implemented the 
MDS+ in Fall 1990 with the approval of the Health 
Standards and Quality Bureau. States collected and 
reviewed over 3 million MDS+ documents on over 
500.000 different residents assessed between 
September 1990 and July 1996. In developing the 
payment systems, facility cost reports and resident 
characteristic data were analyzed to determine the case 
mix of residents and patterns of service use. Kansas 
implemented its Medicaid payment system in January 
1994. The Medicare case-mix-adjusted payment system 
was implemented in August 1995. The quality-monitoring 
information system has been tested, and 30 quality 
indicators are being used for monitoring facility-level and 
resident-level quality. 



Status: The project has conducted a field test of the 
minimum data set on 6,660 nursing home residents. The 
average direct-care staff time across the States is 
115 minutes per day per resident. A new patient 
classification system and a Multistate Medicare/Medicaid 
Payment Index containing 44 groups has been created. 
Maine uses all 44 groups and the nursing index in its 
Medicaid system. States implemented the MDS+ in 
Fall 1990 with the approval of the Health Standards and 
Quality Bureau. States collected and reviewed over 
3 million MDS+ documents on over 500,000 different 
residents assessed between September 1990 and 
July 1996. In developing the payment systems, resident 
characteristic data and facility cost reports were analyzed 
to determine the case mix of residents and patterns of 
service utilization. Maine began implementing its 
Medicaid payment system on October 1, 1993. The 
Medicare case-mix-adjusted payment system was 
implemented in Maine in July 1995. The quality- 
monitoring information system has been tested, and 
30 quality indicators are being used for monitoring 
facility-level and resident-level quality monitoring. 



89-055 Multistate Nursing Home Case-Mix and 
Quality Demonstration: Maine (Formerly, The 
Multistate Nursing Home Case-Mix and Quality 
Demonstration) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-C-99363/1 

June 1989-December 1998 
S 1,290,838 
Cooperative Agreement 

Andrew Coburn, Ph.D. 

Maine Department of Human Services 

Bureau of Medical Services 

State House Station No. 1 1 

Augusta, ME 04333 

Elizabeth S. Cornelius 

Division of Payment Systems 



Description: This project builds on past and current 
initiatives with nursing home case-mix payment and 
quality assurance. The 6-year demonstration will design, 
implement, and evaluate a combined Medicare and 
Medicaid nursing home resident classification and 
payment system in Kansas, Maine, Mississippi, and South 
Dakota. The purpose of the demonstration is to test a 
resident information system with variables for classifying 
residents into homogeneous resource use groups for 
equitable payment and for quality monitoring of outcomes 
adjusted for case mix. The new minimum data set plus 
(MDS+) for resident assessment will be used for resident- 
care planning, payment classification, and quality- 
monitoring systems. The project consists of three phases: 
systems development and design, systems implementation 
and monitoring, and evaluation. 



89-056 Multistate Nursing Home Case-Mix and 
Quality Demonstration: Mississippi (Formerly, The 
Multistate Nursing Home Case-Mix and Quality 
Demonstration) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-C-99362/4 
June 1989-December 1998 
$ 1,572,289 
Cooperative Agreement 

Jamie L. Collier 

Office of Governor 

Division of Medicaid 

Robert E. Lee Building, Suite 801 

239 North Lamar Street 

Jackson, MS 39201 

Elizabeth S. Cornelius 

Division of Payment Systems 



Description: This project builds on past and current 
initiatives with nursing home case-mix payment and 
quality assurance. The 6-year demonstration will design, 
implement, and evaluate a combined Medicare and 
Medicaid nursing home resident classification and 
payment system in Kansas, Maine, Mississippi, and South 
Dakota. The purpose of the demonstration is to test a 
resident information system with variables for classifying 
residents into homogeneous resource use groups for 
equitable payment and for quality monitoring of outcomes 
adjusted for case mix. The new minimum data set plus 
(MDS+) for resident assessment will be used for resident- 
care planning, payment classification, and quality- 
monitoring systems. The project consists of three 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



73 



phases — systems development and design, systems 
implementation and monitoring, and evaluation. 

Status: The project has conducted a field test of the 
minimum data set on 6.660 nursing home residents. The 
average direct care staff time across the States is 
1 15 minutes per day per resident. A new patient 
classification system and a Multistate Medicare/Medicaid 
Payment Index containing 44 groups has been created. 
A 35-group variation was approved in January 1993 for 
the Medicaid portion in Mississippi and South Dakota. 
The variation collapses the 12 rehabilitation groups into 
3 groups for Medicaid purposes. States implemented the 
MDS+ in Fall 1990 with the approval of the Health 
Standards and Quality Bureau. States collected and 
reviewed over 3 million MDS+ documents on over 
500.000 different residents assessed between 
September 1990 and July 1996. In developing the 
payment systems, the resident characteristic data and 
facility cost reports have been analyzed to determine the 
case mix of residents and patterns of service utilization. 
In July 1993, Mississippi implemented its Medicaid case- 
mix systems statewide. The Medicare case-mix-adjusted 
payment system was implemented in early 1996. The 
quality-monitoring information system has been tested, 
and 30 quality indicators are being used for monitoring 
facility-level and resident-level quality. 

89-057 Multistate Nursing Home Case-Mix and 
Quality Demonstration: South Dakota (Formerly, 
The Multistate Nursing Home Case-Mix and Quality 
Demonstration) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-C-99367/8 
June 1 989-December 1998 
$ 1,320,290 
Cooperative Agreement 

Carol Job, R.N. 

South Dakota Department of 

Social Services 

Office of Adult Services and Aginj 

700 Governors' Drive 

Pierre, SD 57501 

Elizabeth S. Cornelius 

Division of Payment Systems 



Description: This project builds on past and current 
initiatives with nursing home case-mix payment and 
quality assurance. The 6-year demonstration will design, 
implement, and evaluate a combined Medicare and 
Medicaid nursing home resident classification and 
payment system in Kansas, Maine, Mississippi, and South 
Dakota. The purpose of the demonstration is to test a 
resident information system with variables for classifying 
residents into homogeneous resource use groups for 
equitable payment and for quality monitoring of outcomes 



adjusted for case mix. The new minimum data set plus 
(MDS+) for resident assessment will be used for resident- 
care planning, payment classification, and quality- 
monitoring systems. The project consists of three 
phases — systems development and design, systems 
implementation and monitoring, and evaluation. 

Status: The project has conducted a field test of the 
minimum data set on 6,660 nursing home residents. The 
average direct care staff time across the States is 
1 15 minutes per day per resident. A new patient 
classification system and a Multistate Medicare/Medicaid 
Payment Index containing 44 groups has been created. A 
35-group variation was approved in January 1993 for the 
Medicaid portion in Mississippi and South Dakota. The 
variation collapses the 12 rehabilitation groups into 
3 groups for Medicaid purposes. The States implemented 
the MDS+ in Fall 1990 with the approval of the Health 
Standards and Quality Bureau. The States have collected 
and reviewed over 3 million MDS+ documents on over 
500,000 different residents assessed between September 
1990 and July 1996. In developing the payment systems, 
the resident characteristic data and facility cost reports 
were analyzed to determine the case mix of residents and 
patterns of service utilization. In July 1993, South Dakota 
implemented its Medicaid case-mix systems statewide. 
The Medicare case-mix-adjusted payment system was 
implemented in January 1996. The quality-monitoring 
information system has been tested, and 30 quality 
indicators are being used for monitoring facility-level and 
resident-level quality. 

90-019 New York Case-Mix Payment and 
Quality Demonstration 

Project No.: 95-C-99540/2 

Period: May 1 990-December 1998 

Funding: $981,718 

Award: Cooperative Agreement 

Principal 

Investigator: Robert W. Barnett 

Awardee: New York State Department of Health 

Empire State Plaza 
Room 1683, Corning Tower 
Albany, NY 12237 

HCFA Project Elizabeth S. Cornelius 

Officer: Division of Payment Systems 

Description: New York State will participate in the 
multistate Nursing Home Case-Mix and Quality 
(NHCMQ) Demonstration. The objective of the 
demonstration is to test the feasibility and cost 
effectiveness of a case-mix payment system for nursing 
facility services under the Medicare and Medicaid 
programs that are based on a common patient 
classification system. The addition of New York State 
enhances the Health Care Financing Administration's 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



ability to project the results of the demonstration on a 
national basis. New York represents a heavily regulated, 
northern, industrialized area with larger, high-cost 
nursing facilities that are medically sophisticated and 
highly skilled. Sixteen percent of the national Medicare 
skilled nursing facility (SNF) days are incurred in New 
York State. New York is uniquely suited for inclusion 
because it already has implemented a complementary 
system for its Medicaid nursing facility payment program. 

Status: In early 1991, the project staff completed the 
minimum data set field test in 25 facilities on 
993 residents. These data have been added to the database 
and analyzed to develop the new NHCMQ Medicare/ 
Medicaid classification system. The inclusion of the New 
York State data has resulted in the addition of a very high 
rehabilitation group to the upper end of the classification. 
The State has implemented the minimum data set plus 
(MDS+) statewide as its resident assessment instrument. 
In November 1992, New York State began receiving the 
information monthly from all facilities; by July 1, 1996, 
it had received a total of 2,000,000 assessments. In 
developing the Medicare payment system, the 1990 
Medicare cost reports were used, as well as the MDS+ 
data and the Medicare provider analysis and review file. 
The Medicare case-mix- adjusted payment system was 
implemented July 1, 1995, in New York. By Summer 
1996, there were over 350 SNFs participating in the SNF 
demonstration, 7 of which are hospital based. 

92-057 Payment of Pharmacists for Cognitive Services 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



ll-C-90229/0 

September 1992-March 1995 

$ 721,588 

Cooperative Agreement 

Dale Christensen, Ph.D. 

State of Washington 

Department of Social and Health Services 

623 Eighth Avenue, SE. 

Olympia, WA 98504-5510 

Kathleen Gondek, Ph.D. 

Division of Payment Systems 

Omnibus Budget Reconciliation Act 
of 1990 (Public Law 101-508) 



Description: The purpose of this demonstration project is 
to test the effect of paying pharmacists for cognitive 
services. The demonstration design includes 
100 treatment and 100 control pharmacies that have 
volunteered to participate. In addition, a comparison 
group of 100 non-volunteer pharmacies will be recruited. 
Washington State will reimburse pharmacists assigned to 
the treatment group for providing cognitive services that 
can be linked to a prescription problem and that involve a 



change in prescription, a decision not to dispense, or an 
extension of patient counseling. Pharmacists will receive 
$4 for an intervention of 6 minutes or less and $6 for an 
intervention of more than 6 minutes. 

Status: This project was implemented on February 1, 
1994. As of September 1996, more than 20,000 cognitive 
service documents were received by the project team. The 
final report is expected January 1997. 

95-055 Per Case Payment to Encourage Risk 
Management and Service Integration in the 
Inpatient Acute-Care Setting 

Project No.: 500-92-00 13DO05 

Period: September 1995-September 1997 

Funding: $511,408 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Janet B. Mitchell, Ph.D. 

Awardee: Health Economics Research, Inc. 

(See page 65) 
HCFA Project Kathleen Gondek, Ph.D. 
Officer: Division of Payment Systems 

Description: The purpose of this project is to design a 
demonstration, conduct a solicitation, and provide 
technical assistance during the implementation of a per 
case payment system. Discounted lump-sum payments 
based on each participating physician hospital 
organization's historical payment experience for all 
diagnosis-related groups (DRGs) will be made to the 
representative organization. The demonstration sites will 
be called Medicare physician-provider partnerships. The 
demonstration seeks to measure actual provider 
behavioral response, patient satisfaction, health outcomes, 
and overall impact on the Medicare program, given a 
financial risk-sharing intervention for acute Medicare 
Part A and Part B inpatient services. This demonstration 
is intended to provide important understanding about the 
administrative complexities, their associated costs, and 
other implementation issues surrounding a medical staff 
payment approach. This demonstration builds on research 
conducted under two prior studies (contract numbers 
500-92-0020DO07 and 18-C-90038/3) investigating 
alternative payment options for medical staffs that would 
promote efficiency and improve service delivery during 
acute inpatient stays. 

Status: The design report for this project has been 
completed. 

95-076 Phase II Implementation of the Home Health 
Agency (HHA) Prospective Payment Demonstration 

Project No.: 500-95-0011 

Period: September 1995-September 1999 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



75 



Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



S 1.811,184 
Contract 



Henry Goldberg 

Abt Associates, Inc. 

55 Wheeler Street 

Cambridge, MA 02138 
HCFA Project J. Donald Sherwood 
Officer: Division of Payment Systems 

Mandate: Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 

Description: This contract implements and monitors 
Phase II of the Home Health Agency (HHA) Prospective 
Payment Demonstration. Under Phase II, a single 
payment per episode approach will be tested for Medicare- 
covered home health care. HHA participation is 
voluntary. It is expected that approximately 100 agencies 
in California, Florida, Illinois, Massachusetts, and Texas 
will participate in the demonstration. HHAs that agree to 
participate will be Randomly assigned to either the 
prospective payment method or a control group that 
continues to be reimbursed in accordance with the current 
Medicare retrospective cost system. HHAs will participate 
in the demonstration for 3 years. 

Status: Phase II recruitment began in Fall 1994 under a 
previous contract with Abt Associates, Inc. The HHA 
entered into the demonstration at the beginning of their 
fiscal years. Several HHAs began receiving per episode 
payments in June 1994, with the majority entering the 
demonstration in January 1996. The episodic payment 
rates are prospectively set for each HHA, reflecting their 
previous practice and cost experience. Rates are to be 
adjusted annually. As a protection to both the HHAs and 
the Medicare program, there will be retrospective 
adjustments for sharing of gains or losses and for changes 
in an HHA's projected case mix. 

94-093 Physician Capitation for Medicare Services: 
Feasibility Study and Demonstration Design 

Project No. : 500-92-00 1 1 DO04 

Period: January 1994-March 1996 

Funding: $ 305,596 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Lyle Nelson, Ph.D. 

Awardee: Mathematica Policy Research, Inc. 

(See page 65) 
HCFA Project Brigid Goody, Sc.D. 
Officer: Division of Delivery Systems and 

I inancing 

Description: The purpose of this project is to build on an 
earlier Health ( are financing Administration (HCFA) 



funded project in which Mathematica Policy Research, 
Inc. (MPR), and the Medical Group Management 
Association (MGMA) designed a demonstration of direct 
capitation of medical groups. In this project, the 
contractor considers a broader range of risk-based 
payment arrangements and expands the set of potential 
demonstrations to include independent practice 
associations and integrated delivery systems in addition to 
medical groups. The project also includes an analysis of 
HCFA data to explore the feasibility of bundling for 
selected medical conditions. 

Status: A final report, "Should Medicare Place Physician 
Groups at Financial Risk: An Assessment of Alternative 
Demonstration Strategies," is available from the National 
Technical Information Service, accession number 
PB96- 172804. This report presents an examination of the 
extent to which physician groups currently accept risk 
from health maintenance organizations (HMOs) and other 
managed-care organizations, an evaluation of a variety of 
risk-based payment options, and a synopsis of discussions 
with provider representatives. The investigators report 
that there are mixed feelings among physician groups 
regarding potential interest in a demonstration of risk- 
based payment under Medicare. Although many physician 
groups have entered into risk-based arrangements with 
HMOs, attempts to develop similar arrangements between 
physician groups and the Medicare program would 
present some unique challenges. In particular, physician 
groups would be responsible for many functions currently 
performed by HMOs, including the development of 
insurance products attractive to beneficiaries and 
administrative functions including paying provider 
claims. 

A second final report, "An Assessment of Condition- 
Based Bundling as a Payment Option for Medicare," 
accession number PB96- 174925, is available from the 
National Technical Information Service. The report is 
composed of two parts: a conceptual analysis of how a 
demonstration for condition-based bundling would 
operate and a statistical analysis of Medicare claims data 
to assess the suitability of several medical conditions for 
condition-based bundling. The statistical analysis focuses 
on six conditions: three acute conditions (hip fracture, 
acute myocardial infarction, and septicemia) and three 
chronic conditions (diabetes, heart failure, and glaucoma). 
The investigators concluded that hip fracture deserves 
additional consideration for a bundling demonstration. 

90-017 Policy Study of the Cost Effectiveness 
of Institutional Subacute Care Alternatives 
and Services: 1984-92 



Project No.: 

Period: 

Funding: 



18-C-99491/8 
May 1990-August 
$ 1,427,400 



995 



76 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



Award: 
Principal 
Investigator: 
Awardee: 



Cooperative Agreement 



Andrew Kramer, M.D. 

University of Colorado 

Health Sciences Center 

1355 South Colorado Boulevard 

Denver, CO 80222 
HCFA Project Judith A. Sangl, Sc.D. 
Officer: Division of Health Information and 

Outcomes 

Description: The University of Colorado will assess which 
subacute institutional settings and combinations of 
services are most cost-effective and provide more positive 
outcomes for various types of patients. Researchers will 
identify potential Health Care Financing Administration 
(HCFA) policy changes that might encourage use of the 
most appropriate settings and services. This project will 
use primary and secondary data from three previous 
HCFA-sponsored studies to compare quality, cost 
effectiveness, case mix, service mix, and utilization 
among institutional subacute care alternatives (e.g., 
skilled nursing facilities (SNFs) and rehabilitation 
hospitals) within and between two periods: 1984-87 and 
1990-92; the longitudinal admission sample is for the 
period 1992-94. This methodology is designed to 
determine the most cost-effective combinations of services 
and provider settings for various types of patients 
requiring subacute care (i.e., stroke and hip fracture). 
Functional-related groups and alternative groupings will 
be tested to explain variation in resource consumption. 
Several prospective and per case payment methods for 
selected types of subacute care will be modeled. 

Status: Preliminary longitudinal analyses indicate 
different results regarding hip fracture and stroke 
outcomes and cost-effectiveness between rehabilitation 
and skilled nursing facilities (SNFs). With respect to hip 
fractures: 

• Patients with an amputation should be placed in 
rehabilitation facilities. 

• Comparable hip fracture patients have equivalent 
outcomes at lower costs in SNFs. 

• Comparable hip fracture patients have equivalent 
outcomes in high-Medicare volume subacute SNFs and 
low-Medicare volume SNFs, despite cost differences. 

With respect to stroke patients: 

• Patients with coma, grade 3 or 4 pressure sores, the 
inability to walk 20 feet before their stroke should be 
placed in SNFs. 

• Comparable stroke patients have better outcomes in 
rehabilitation facilities than SNFs, but at higher cost. 

• Comparable stroke patients have better outcomes in 
high-Medicare volume subacute SNFs than low- 
Medicare volume SNFs, but at higher cost. 



• Functional outcomes at 6 months are better for some 
stroke patients admitted to rehabilitation facilities than 
high-Medicare volume subacute SNFs, but at higher 
cost. 

96-056 Program for All-inclusive Care for the 
Elderly (PACE) Quality Assurance 

Project No.: 500-96-0004/0002 

Period: September 1996-March 1999 

Funding: $ 1,837,148 

Award: Long-Term-Care Task Order 

Principal 

Investigator: Peter Shaughnessy, Ph.D. 

Awardee: Center for Health Policy Research 

1355 S. Colorado Blvd, Suite 306 

Denver, CO 80222 
HCFA Project Elizabeth Mauser, Ph.D. 
Officer: Division of Aging and Disability 

Description: This project will develop an outcome-based 
quality assurance and performance improvement system 
for the Program for All-Inclusive Care for the Elderly 
(PACE) for use by Health Care Financing Administration 
(HCFA) and States in monitoring sites and for continuous 
quality improvement (CQI). The CQI system will consist 
of two phases. In the first phase risk-adjusted outcome 
reports will be produced, while during the second phase 
the PACE sites will examine why and how they are 
achieving specific outcomes and make recommendations 
for improvements in the case of poor outcomes. 

Status: This project is currently in its design phase. 

93-051 Prospective Per Case Payment for Episodes of 
Hospital Care (Formerly, Per Case Prospective Payment 
for Episodes of Hospital Care) 

Project No. : 500-92-0020 DO07 

Period: June 1993-October 1995 

Funding: $ 644,052 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Janet B. Mitchell, Ph.D. 

Awardee: Health Economics Research, Inc. 

(See page 193) 

HCFA Project Teresa L. DeCaro 

Officer: Division of Payment Systems 

Description: This study seeks to produce alternative 
prospective per case payment models for episodes of 
hospitalization that expand the current boundaries of 
payment consolidation under Medicare's fee-for-service 
reimbursement policies. Specific tasks include: defining 
episodes of care that are anchored to acute 
hospitalizations; analyzing service bundles that make up 
the episodes; identifying and analyzing design, 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



77 



administrative, legal, transition, and other issues 
important to the potential implementation of selected 
models; calculating payment weights; and conducting 
"spending-neutral" impact simulations of selected 
payment models. A technical advisory panel (TAP) made 
up of experts in research, medicine, group practice and 
hospital administration, claims data collection and 
management, and contract negotiations is providing 
guidance and feedback to the awardee throughout the life 
of the project. 

Status: Using the Health Care Financing Administration's 
1992. 5-month, 100-percent hospital admission and 
episode database, descriptive analyses of physician service 
bundles are presented in an interim report. Bundles 
include all physician services associated with an acute 
hospitalization from the day of admission to the day of 
discharge. Expanded bundles including windows up to 
30 days prior to admission and 90 days post-discharge are 
also examined. These data are analyzed for 
appropriateness of window definitions and systematic 
differences in severity of illness within diagnosis-related 
groups (DRGs) by hospital characteristics. The final 
report. "Per Case Prospective Payment for Episodes of 
Hospital Care," is available from the National Technical 
Information Service, accession number, PB96-174917. 
This report provides standardized national weights based 
on payment models that include all DRGs for services 
provided during the inpatient stay. One model bundles 
physician services only. Another combines facility 
prospective payment with bundled physician services. The 
models assume payment based on a national average for 
each DRG, adjusted for outliers, transfers, teaching and 
disproportionate share, and geographic cost differences. 
Impact simulations are reported by hospital type and 
geographic region. Case payment could result in 
considerable redistribution across medical staffs. Medical 
staffs in teaching hospitals and in large urban hospitals 
would lose money on average, while those in non- 
teaching and in rural hospitals would make money. Staffs 
in the Mid-Atlantic region would experience large losses, 
while those in the West (particularly in sparsely populated 
States) would gain. Assuming a DRG-specific lump-sum 
payment for each admission would be made to an entity 
representing physicians in the first case, and both 
physicians and hospitals in the second, case studies were 
conducted and are presented which examine provider, 
administrative, and legal issues. Policy implications are 
explored including model refinements and transition 
options that could minimize the redistributional 
consequences of implementing a per case payment policy 
nationally. 



92-034 Randomized Controlled Trial of Expanded 
Medical Care in Nursing Homes for Acute Care 
Episodes: Monroe County Longterm Care Program, 
Inc. (Formerly, A Randomized Controlled Trial of 
Expanded Medical Care in Nursing Homes for Acute Care 
Episodes) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



95-C-90151/2 

March 1992-August 1996 

$ 1,054,007 
Cooperative Agreement 

Gerald Eggert, Ph.D. 

Monroe County Long Term Care 

Program, Inc. 

349 West Commercial Street, Suite 2250 

Piano Works 

East Rochester, NY 14445 

Carolyn Rimes 

Division of Aging and Disability 



Description: The objective of this demonstration is to 
develop, implement, and evaluate the effectiveness of 
expanded medical services to nursing home residents who 
are undergoing acute illnesses that would ordinarily 
require hospitalization. The intervention will include 
many services that are available in acute hospitals and are 
feasible and safe in nursing homes. These include an 
initial physician visit, all necessary followup visits, 
diagnostic and therapeutic services, and additional 
nursing care (including private duty), if necessary. The 
major goals are to reduce medical complications and 
dislocation trauma resulting from hospitalization and to 
save the expense of hospital care when patients could be 
managed safely in nursing homes with expanded services. 

Status: The design phase of the demonstration has been 
completed. The design is currently being evaluated to 
determine the impact of the implementation of the Multi- 
state Nursing Home Case-Mix and Quality Demonstration 
on the implementation of this demonstration. 

96-037 Refinements to Medicare DCG 
Risk-Adjustment Models: Task Order: 
Health Economics Research, Inc. 

Project No.: 500-95-0048TO03 

Period: September 1996-July 1997 

Funding: $ 1 14,897 

Award: Task Order in Basic Order Contract 

Principal 

Investigator: Gregory C. Pope 

Awardee: Health Economics Research, Inc. 

(Seepage 198) 
HCFA Project Melvin J. Ingber, Ph.D. 
Officer: Division of Delivery Systems and 

Financing 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



Description: This project will develop further revisions to 
the risk-adjuster system described in identifier 93-045. 
This is the system derived from the diagnostic-cost-group 
(DCG) model for the Medicare incorporating diagnoses 
from both inpatient and ambulatory encounters. The 
project will classify codes from the International 
Classification of Diseases, 9th Revision, Clinical 
Modification that have changed since 1994, refine 
prediction for the disabled population, refine the 
concurrent year models, and examine the need for other 
changes. 

Status: The project is in the initial phases. 

96-058 Risk Adjustment for Medicaid 
Recipients with Disabilities 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-90599/9-01 
August 1996-July 1998 
$ 50,000 
Cooperative Agreement 

Richard Kronick, Ph.D. 

University of California at San Diego 

9500 Gilman Drive 

La Jolla, CA 92093 

Elizabeth Mauser, Ph.D. 

Division of Aging and Disability 



Description: The objective of this project is to develop a 
diagnostically based, risk-adjusted payment system that 
may be used by State Medicaid programs when 
contracting on a capitated basis with health plans for 
Medicaid recipients with disabilities. The project will use 
data from three States (California, Georgia, and 
Tennessee). In addition to developing a risk-adjustor 
payment system, the authors will identify solutions to 
implementation problems that States are likely to 
encounter. 

Status: Tape-to-tape data from California, Georgia, and 
Tennessee have been ordered. Once these data are 
received, the analysis phase of the project will begin. 

94-122 Risk-Adjusted Payment Models 
for the Non-Elderly 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



18-C-90462/1 

September 1 994-September 1997 

$ 802,651 

Cooperative Agreement 

Arlene Ash 
Boston University 
80 East Concord Street 
Boston, MA 02118 



HCFA Project Melvin J. Ingber, Ph.D. 
Officer: Division of Delivery Systems and 

Financing 

Description: This project will develop a revised 
classification system based on the diagnostic-cost-group 
(DCG) model for the population under 65 years of age 
that would incorporate diagnoses from both inpatient and 
ambulatory encounters. A similar model is being 
developed for the Medicare population under identifier 
93-045. The revised DCGs classify diagnoses by clinical 
and future cost implications. A hierarchy of diagnoses 
within body systems results in the dominance of the most 
serious disease in each category. There may be coded 
multiple comorbidities across systems, however. The 
project will use data from several sources: CalPers (the 
five largest participating plans), Medicaid Statistical 
Information System (three States), MedStat, and data 
from Massachusetts State employees and dependents. The 
data cover 1991-94 and include approximately 2 million 
covered lives. 

Status: The project is in the process estimating models 
and refining the final groupings. 

96-078 RUG HI Validation for National Skilled 
Nursing Facility (SNF) Payment System 

Project No.: 500-96-0027 

Period: September 1995-March 1998 

Funding: $ 841,197 

Award: Contract 

Principal 

Investigator: Robert E. Burke, Ph.D. 

Awardee: Allied Technology Group, Inc. 

1803 Research Boulevard, Suite 601 

Rockville, MD 20850 
HCFA Project J. Donald Sherwood 
Officer: Division of Payment Systems 

Description: The purpose of this contract is to examine 
and report on the differences and similarities in practice 
patterns across the States by conducting additional staff 
time measurement studies in skilled nursing facilities 
(SNFs) in States identified as providing more than the 
average level of rehabilitation services on Medicare units, 
and in units identified as "subacute" Medicare providers. 
The study will be conducted in California, Colorado, 
Florida, and Maryland. A stratified sample of free- 
standing and hospital based facilities will be used and will 
include units in both settings that are identified as 
subacute by a technical-expert panel representing the SNF 
industry, therapists, and other experts from the research 
community. 

Status: The contract was awarded the end of 
September 1996. The sampling framework is being 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



79 



constructed; it is expected that 55 SNFs will participate 
across the four States. The technical-expert panel will 
meet in early December. The data collection phase is 
scheduled to begin in early 1997. 

95-085 Second Generation Social Health Maintenance 
Organization Demonstration: California 

Project No.: 95-C-90493/9-0 1 

Period: November 1 996— December 1997 

Award: Waiver-only Project 

Principal 

Investigator: Bobbi Baron 

Awardee: Contra Costa County Health Plan 

595 Center Avenue, Suite 100 

Martinez, CA 94553 
HCFA Project Dennis M. Nugent 
Officer: Division of Aging and Disability 

Mandate: Section 4207(b)(4) of the Omnibus 

Budget Reconciliation Act of 1990 
(Public Law 101-508) 

Description: In accordance with section 2355 of Public 
Law 98-369, the concept of a social health maintenance 
organization (S/HMO) was developed and implemented. 
The S/HMO integrates health and social services under 
the direct financial management of the provider of 
services. All acute and long-term-care services are 
provided by or through the S/HMO at a fixed, annual, 
prepaid capitation sum. The Omnibus Budget 
Reconciliation Act of 1990 authorized the expansion of 
the social health maintenance organization 
demonstration. The purpose of this second generation 
S/HMO (S/HMO-II) demonstration is to refine the 
targeting and financing methodologies and the benefit 
design of the current S/HMO model. The S/HMO-II 
model will also provide an opportunity to test more 
geriatrically oriented models of care. Six organizations 
have been awarded waivers to implement the project. 

Status: Enrollment in this S/HMO-II demonstration site is 
scheduled to begin in May 1997. At the current time 
preimplementation activities are being completed. 

95-090 Second Generation of Social Health 
Maintenance Organization Demonstration: Colorado 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



95-C-90498/8-01 

November 1996-December 1997 

Waiver-only Project 

Margaret Hearndon 
Rocky Mountain Health 
Maintenance Organization 
2775 Crossroads Boulevard 
Grand Junction, CO 81506 



HCFA Project Melissa Hulbert, MPS 

Officer: Division of Aging and Disability 

Mandate: Omnibus Budget Reconciliation Act 

of 1990 

Description: In accordance with section 2355 of Public 
Law 98-369, the concept of a social health maintenance 
organization (S/HMO) was developed and implemented. 
The S/HMO integrates health and social services under 
the direct financial management of the provider of 
services. All acute and long-term-care services are 
provided by or through the S/HMO at a fixed, annual, 
prepaid capitation sum. The Omnibus Budget 
Reconciliation Act of 1990 authorized the expansion of 
the social health maintenance organization 
demonstration. The purpose of this second-generation 
S/HMO (S/HMO-II) demonstration is to refine the 
targeting and financing methodologies and the benefit 
design of the current S/HMO model. The S/HMO-II 
model should also provide an opportunity to test geriatric- 
oriented models of care. Six sites have been selected to 
participate in the S/HMO-II demonstration. 

Status: Waivers have been awarded and Rocky Mountain 
HMO is preparing to implement the demonstration. 

95-091 Second Generation of Social Health 
Maintenance Organization Demonstration: Florida 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



95-C-90501/4-01 

November 1 996— December 1997 

Waiver-only Project 

JoAnne Dutcher 

CAC Ramsey Health Plan 

75 Valencia Avenue 

Coral Gables, FL 33134 

Melissa Hulbert, MPS 

Division of Aging and Disability 

Omnibus Budget Reconciliation Act 
of 1990 



Description: In accordance with section 2355 of Public 
Law 98-369, the concept of a social health maintenance 
organization (S/HMO) was developed and implemented. 
The S/HMO integrates health and social services under 
the direct financial management of the provider of 
services. All acute and long-term-care services are 
provided by or through the S/HMO at a fixed, annual, 
prepaid capitation sum. The Omnibus Budget 
Reconciliation Act of 1990 authorized the expansion of 
the social health maintenance organization 
demonstration. The purpose of this second generation 
S/HMO (S/HMO-II) demonstration is to refine the 
targeting and financing methodologies and the benefit 
design of the current S/HMO model. The S/HMO-II 



80 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



model should also provide an opportunity to test geriatric- 
oriented models of care. Six sites were selected to 
participate in the demonstration. 

Status: Waivers have been awarded and CAC-United is 
preparing to implement the demonstration. 

95-086 Second Generation of Social Health 
Maintenance Organization Demonstration: 
Massachusetts 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



95-C-90496/1-01 
November 1 996— December 
Waiver-only Project 



997 



Linda Fitzpatrick 

Fallon Community Health Plan 

Chestnut Place 

10 Chestnut Street 

Worcester, MA 01608 

Dennis M. Nugent 

Division of Aging and Disability 

Section 4207(b)(4) of the Omnibus 
Budget Reconciliation Act of 1990 
(Public Law 101-508) 



Description: In accordance with section 2355 of Public 
Law 98-369, the concept of a social health maintenance 
organization (S/HMO) was developed and implemented. 
The S/HMO integrates health and social services under 
the direct financial management of the provider of 
services. All acute and long-term-care services are 
provided by or through the S/HMO at a fixed, annual, 
prepaid capitation sum. The Omnibus Budget 
Reconciliation Act of 1990 authorized the expansion of 
the social health maintenance organization 
demonstration. The purpose of this second-generation 
S/HMO (S/HMO-II) demonstration is to refine the 
targeting and financing methodologies and the benefit 
design of the current S/HMO model. The S/HMO-II 
model will also provide an opportunity to test more 
geriatrically oriented models of care. Six organizations 
have been awarded waivers to implement the project. 

Status: Enrollment in this S/HMO-II demonstration site is 
scheduled to begin in May 1997. At the current time, 
preimplementation activities are being completed. 

95-088 Second Generation of Social Health 
Maintenance Organization Demonstration: Nevada 



Project No.: 

Period: 

Award: 

Principal 

Investigator: Bonnie Hillegass 



95-C-90503/9-01 

November 1 996-December 1997 

Waiver-only Project 



Awardee: Health Plan of Nevada, Inc. 

P. O. Box 15645 

Las Vegas, NV 891 14 
HCFA Project Dennis M. Nugent 
Officer: Division of Aging and Disability 

Mandate: Section 4207(b)(4) of the Omnibus 

Budget Reconciliation Act of 1990 
(Public Law 101-508) 

Description: In accordance with section 2355 of Public 
Law 98-369, the concept of a social health maintenance 
organization (S/HMO) was developed and implemented. 
The S/HMO integrates health and social services under 
the direct financial management of the provider of 
services. All acute and long-term-care services are 
provided by or through the S/HMO at a fixed, annual, 
prepaid capitation sum. The Omnibus Budget 
Reconciliation Act of 1990 authorized the expansion of 
the social health maintenance organization 
demonstration. The purpose of this second-generation 
S/HMO (S/HMO-II) demonstration is to refine the 
targeting and financing methodologies and the benefit 
design of the current S/HMO model. The S/HMO-II 
model will also provide an opportunity to test geriatric- 
oriented models of care. Six organizations have been 
awarded waivers to implement the project. 

Status: The Health Plan of Nevada began enrolling 
Medicare beneficiaries into the S/HMO-II demonstration 
in November 1996. 

95-087 Second Generation of Social Health 
Maintenance Organization Demonstration: 
South Carolina 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



95-C-90500/4-01 

November 1 996-December 1997 

Waiver-only Project 

Thomas Brown, Ph.D. 

Richland Memorial Hospital 

Five Richland Medical Park 

Columbia, SC 29203 

Dennis M. Nugent 

Division of Aging and Disability 

Section 4207(b)(4) of the Omnibus 
Budget Reconciliation Act of 1990 
(Public Law 101-508) 



Description: In accordance with section 2355 of Public 
Law 98-369, the concept of a social health maintenance 
organization (S/HMO) was developed and implemented. 
The S/HMO integrates health and social services under 
the direct financial management of the provider of 
services. All acute and long-term-care services are 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



81 



provided by or through the S/HMO at a fixed annual 
prepaid capitation sum. The Omnibus Budget 
Reconciliation Act of 1990 authorized the expansion of 
the social health maintenance organization 
demonstration. The purpose of this second-generation 
S HMO (S/HMO-II) demonstration is to refine the 
targeting and financing methodologies and the benefit 
design of the current S/HMO model. The S/HMO-II 
model will also provide an opportunity to test more 
geriatrically oriented models of care. Six organizations 
have been awarded waivers to implement the project. 

Status: Enrollment in this S/HMO-II demonstration site is 
scheduled to begin in May 1997. At the current time, 
preimplementation activities are being completed. 

95-002 Second Revision of the Medicare 
Geographic Practice Cost Index (GPCI) 

Project No.: 500-92-0020 

Period: July 1 995-December 1996 

Funding: $ 155,012 

Award: Contract 

Principal 

Investigator: Gregory C. Pope, Ph.D. 

Awardee: Health Economics Research, Inc. 

(See page 193) 

HCFA Project Benson L. Dutton 

Officer: Division of Payment Systems 

Mandate: Omnibus Reconciliation Act of 1990 

(Public Law 101-508) 

Description: By law, the Health Care Financing 
Administration (HCFA) is mandated to review and if 
necessary update the Geographic Practice Cost Index 
(GPCI) every 3 years. HCFA is required to use the best 
and most current data available to complete this task. 
Health Economics Research, Inc. (HERI) has been 
awarded a contract to review and revise the 1999 GPCI. 
HERI reviewed current GPCI components that included: 
cost shares; wage indices; office rental index; malpractice 
premium index; relative value units and population 
weights; and geographic definition/crosswalks. These 
elements will be used to recommend changes in the work, 
practice expense, and malpractice GPCIs. The impact of 
changes in the components and the redistributional effects 
resulting from the revision were considered. Based on 
their findings HERI recommends: no update to the GPCI 
wage indices; elimination of county adjustments in all 
metropolitan areas (except New York City); updating the 
malpractice GPCI with the three most recent years of 
malpractice premium data from the HCFA-sponsored 
survey of malpractice insurers; and keeping cost shares 
consistent with those used in the Medicare Economic 
Index. 



Status: To date, HERI has delivered a draft final report 
providing project detail describing their analytical 
methods, findings, conclusions, and recommendations. 

93-078 Site Development and Technical Assistance for 
the Second Generation of Social Health Maintenance 
Organization Demonstrations 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



500-93-0033 

September 1993-September 1998 

$ 2,251,123 

Contract 

Robert L. Kane, M.D. 

University of Minnesota 

School of Public Health 

Institute for Health Services Research 

D-351 Mayo Memorial Building 

420 Delaware Street, SE., Box 197 

Minneapolis, MN 55455-0392 

Dennis M. Nugent 

Division of Aging and Disability 

Section 4207(b)(4) of the Omnibus Budget 
Reconciliation Act of 1990 
(Public Law 101-508) 



Description: In January 1995, the Health Care Financing 
Administration selected six organizations to participate in 
the Second Generation of Social Health Maintenance 
Organization (HMO) Demonstration. The purpose of this 
project is to study the impact of integrating acute- and 
long-term care services within a capitated managed-care 
system. It was developed to refine the targeting and 
financing methodologies and the benefit design of the 
current social HMO model which was initiated as a 
demonstration in 1985. 

Although the same services are provided under both of 
these projects the second generation social HMO 
demonstration features a greater emphasis on geriatric 
care and a more inclusive case management system. 
Another distinguishing characteristic of the project is its 
risk-adjusted payment methodology that is based on an 
individual's health status and functioning level. The 
primary focus of the project's evaluation will be to 
compare beneficiaries enrolled in the demonstration with 
beneficiaries in a section 1876 HMO program. 
The University of Minnesota and its subcontractor, the 
University of California at San Francisco, are providing 
technical assistance and support in the development, 
implementation, and operation of the second generation 
social HMO demonstration. 

Status: The developmental phase of the second generation 
social HMO demonstration began in January 1995. Since 



82 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



that time the University of Minnesota and the University 
of California at San Francisco have been providing 
technical assistance to the organizations participating in 
the project. They have also developed a questionnaire that 
will be used to determine a beneficiary's capitated 
payment rate, a series of geriatric protocols to help 
physicians identify and treat certain health conditions, 
and a care coordination assessment instrument to assist 
case managers with care planning. The Health Plan of 
Nevada began enrolling beneficiaries into the 
demonstration in November 1996. Enrollment at the other 
five organizations is scheduled to begin in May 1997. 

92-048 Sources of Medicare Home Health Expenditure 
Growth: Implications for Control Options 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



17-C-90107/1 

February 1 992-December 1995 

$ 210,706 

Cooperative Agreement 

Christine Bishop, Ph.D. 
Brandeis University 
Heller Graduate School 
Institute for Health Policy 
415 South Street 
P.O. Box 91 10 
Waltham, MA 02254-9110 
J. Donald Sherwood 
Division of Payment Systems 



Description: The overall objective of the project is to 
develop and consider options for restraining home health 
expenditure growth. The project has two phases. First is 
to use secondary data to examine the composition of 
Medicare home health expenditure growth between 1985 
and 1989 and 1989 to 1991 to attribute total growth to 
growth in persons served, visits per person, mix of visits, 
and visit charges; and to attribute growth to types of 
agencies by auspice and scale. Second is to examine data 
from the Regional Home Health Intermediary database to 
measure variation in types of patients served at intake, 
and the characteristics of high-use patients, by auspice 
and region, and to consider differences in mix and 
intensity of services provided. 

Status: The first phase has been completed, resulting in 
an overview, "Recent Growth in Medicare Home Health: 
Sources and Implications." An edited version of this 
analysis, "Recent Growth of Medicare Home Health," by 
Christine Bishop, Ph.D., and Kathleen Carley Skwara, 
was published in Health Affairs, Volume 12, Number 3, 
pp. 95-1 10, Fall 1993. The second phase will analyze the 
length of Medicare home health episodes using survival 
analysis techniques. A report for this phase is expected 
in 1997. 



93-039 State Primer on All-Payer Systems for 
Health Care Services (Formerly, Assessing the 
Viability of All-Payer Systems for Health Care 
Services: Health Economics Research, Inc.) 

Project No.: 500-92-0020DO04 

Period: May 1993-September 1995 

Funding: $ 337,542 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Jerry Cromwell, Ph.D. 

Awardee: Health Economics Research, Inc. 

(See page 193) 

HCFA Project Jesse M. Levy, Ph.D. 

Officer: Division of Payment Systems 

Description: Interest in health care reform has spread 
along multiple dimensions. In addition to national 
initiatives, there are State initiatives; in addition to 
managed-care initiatives, there are single-payer, multiple- 
payer, and all-payer ratesetting initiatives. The purpose of 
this project is to produce a primer to inform States on the 
issues that would have to be addressed to design and 
implement an all-payer ratesetting system for physician 
and hospital services. 

Status: The final report is available from the National 
Technical Information Service, accession number, 
PB96- 162292. 

94-129 Sustainable Support System for 
Telemedicine Research and Evaluation 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-90413/0 

September 1994-March 1996 

$ 246,296 

Cooperative Agreement 

Douglas A. Perednia, M.D. 
Telemedicine Research Center 
7276 Southwest Beaverton-Hillsdale 
Highway, Suite 187 
Portland, OR 97225 
William L. England, Ph.D., J.D. 
Division of Health Information and 
Outcomes 



Description: The goal of this project was to create an 
effective, ongoing mechanism by which the cost, 
effectiveness, and utility of telemedicine services could be 
systematically evaluated. This was done through 
formation of a Clinical Telemedicine Cooperative Group 
(CTCG). The CTCG is based at the Telemedicine 
Research Center, a non-profit public service research 
corporation in Portland, Oregon, formed to foster high- 
quality research in telemedicine. The CTCG is modeled 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



83 



after a successful cooperative multi-centered research 
organization. Functions of the CTCG include: 

• Providing operational and statistical support for 
telemedicine research and evaluation. 

• Maintaining a communication system to link 
geographically distant telemedicine projects to share 
information and perform telemedicine research. 

• Creating easily adaptable electronic data collection and 
tabulation instruments for use in telemedicine research. 

• Building a comprehensive on-line telemedicine 
information clearinghouse for gathering, storing, and 
disseminating information about the utility, 
effectiveness, and suitability of telemedicine for a broad 
range of medical and social applications. 

Status: The Telemedicine Research Center World Wide 
Web site at URL address: http://tie.telemed.org/contimies 
as a resource available to the telemedicine community as a 
result of this project. 

91-080 Teaching Physicians and 
the Medicare Program 

Project No.: 17-C-90015/1 

Period: September 1991-September 1996 

Funding: S 463,765 

Award: Cooperative Agreement 

Principal 

Investigator: Janet B. Mitchell, Ph.D. 

Awardee: Center for Health Economics Research 

300 Fifth Avenue, 6th Floor 

Waltham, MA 02154 
HCFA Project William Buczko, Ph.D. 
Officer: Division of Payment Systems 

Description: Relatively little is known about teaching 
physicians, their practice organization, their billing 
patterns, and their cost to the Medicare program. This 
study will examine practice plans in 10 hospitals to 
determine how practice in teaching hospitals is organized. 
Also, Part A and Part B claims will be merged with 
Medicare Cost Report data to determine the total cost of 
physicians' services in teaching hospitals as well as the 
extent of double payment by physicians. These data also 
will be used to evaluate the impact of the Medicare fee 
schedule on teaching physicians and related effects on 
volume of services performed. 

Status: Site visits to case study hospitals have been 
completed and described in reports for each site. A 
summary report of these findings, "Teaching Physicians 
and the Medicare Program: A Case Study," is available 
from the contractor. Analyses of cost report data and 
interns, and residents, data have been completed and 
presented in a draft report. An analysis of Part A and 
Part B claims in the merged Part A/Part B database has 
been presented in a draft report. Analysis of 1993 Part A 



data and Part B claims for 1992 and 1993 and merged 
Part A/Part B analyses will be completed by 
December 1996. The final report is expected in 
Spring 1997. 

92-028 Texas Medicare Nursing Home 
Case-Mix and Quality Demonstration 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



95-C-90019/6 

February 1992-December 1998 

$ 307,382 

Cooperative Agreement 

Stephen Lorenzen, Ph.D. 

Texas Department of Human Services 

P. O. Box 149030 (MC-E-601) 

Austin, TX 78714-9030 

Elizabeth S. Cornelius 

Division of Payment Systems 



Description: Texas will participate in the multistate 
Nursing Home Case-Mix and Quality (NHCMQ) 
Demonstration. The objective of the demonstration is to 
test the feasibility and cost effectiveness of a case-mix 
payment system for nursing facility services under the 
Medicare and Medicaid programs that are based on a 
common patient-classification system. The addition of 
Texas enhances the Health Care Financing 
Administration's ability to project the results of the 
demonstration on a national basis. Texas represents a 
western pattern of service using more proprietary 
multistate chain providers than is the pattern used in the 
East. Twenty Texas Medicare facilities were part of the 
original data collection for the development of the 
resource-utilization-group (RUG) III system. Texas has 
the second largest number of hospital-based facilities in 
the country. There are more than 20 metropolitan 
statistical areas of varying size. In addition, the State has 
a large number of rural areas. The State was traditionally 
a flat-rate intermediate care facility Medicaid system until 
1989, when it implemented a RUG-type Medicaid 
payment system. This RUG-type payment system makes 
Texas well-suited for inclusion in the Medicare portion of 
the demonstration. 

Status: During the first year of participation, the Texas 
Department of Human Services worked with the Texas 
Department of Health to change the resident assessment 
instrument being used in the State. In April 1993, Texas 
implemented the minimum data set plus statewide as its 
resident assessment instrument. Analyses of 1990 
Medicare Cost Report data, Medicare provider analysis 
and review Part A skilled nursing facility stay data, and 
the Texas Client Assessment and Review Evaluation 
(CARE) data have been conducted for use in developing 
the demonstration's Medicare case-mix payment system. 
Under the Medicaid demonstration, Texas began 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



development of the Quality Evaluation System of Texas, 
a resident characteristic information and reporting system 
using the CARE instrument. During the first year, the 
staff continued the development and enhancement of the 
system, which was codified into Law by the Texas 
Legislature in Summer 1993. They now are producing 
facility-level reports with statewide comparisons for Texas 
providers on a twice-a-year basis. The Medicare portion of 
the NHCMQ demonstration was implemented 
July 1, 1995, in Texas. 

87-009 Texas Nursing Home Case-Mix Demonstration 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-C-99131/6 

September 1987-April 1994 
S 532,830 
Cooperative Agreement 

Ken C. Stedman 

Texas Department of Human Services 

P. O. Box 14930 (MC-E-601) 

Austin. TX 78714-9030 

Elizabeth S. Cornelius 

Division of Pavment Svstems 



Description: This Texas Department of Human Sendees' 
project had two parts. First was to develop, implement, 
and evaluate a Medicaid prospective case-mix payment 
system. The payment system is based on feasibility studies 
sponsored by the Health Care Financing Administration. 
The major Medicaid objectives of this part were to match 
payment rates to resident need, promote the admission of 
heavy-care patients to nursing homes, provide incentives 
to improve quality of care, improve management 
practices, and demonstrate the administrative feasibility 
of the new system. Second was to develop and pilot test a 
case-mix-adjusted prospective payment system (PPS) for 
Medicare patients in skilled nursing facilities. The 
objective of the Medicare pilot test was to develop and 
implement the administrative processes for a Medicare 
PPS in three facilities, based on a resource-utilization- 
group (RUG) classification. The index that was used for 
the classification of Medicare patients was the RUG-T18, 
which uses the same clinical groups and the activities of 
daily living (ADL) scale used in the New York Resource 
Utilization Group. Version II (RUG II) system. The 
difference occurs in the expanded rehabilitation groups 
for Medicare patients. Texas used a quasi-experimental 
design for the Medicare pilot test to compare the effect of 
introducing case-mix payment in a small group of 
experimental facilities in one catchment area versus 
continuing the flat-rate, cost-based system in a control 
catchment area. The State used a pre/postdesign for the 
Medicaid system. Case-mix classifications are based on a 
review of six different systems in which the New York 
RUG II explained the greatest variance of staff time. 



Case-mix indexes borrow major elements of the RUG II 
system and some of the rationale from the Minnesota 
system. The Texas index of level of effort (TILE) uses 
four clinical groups to form clusters and to develop 
subgroups using an ADL scale. A quality of care 
information and reporting system called the Quality 
Evaluation System of Texas (QUEST) was developed and 
tested. Two third-party evaluations were completed: one 
on data reliability and one on the validity of the data 
analysis methods. 

Status: During the first year, the TILE and RUG-T18 
indexes were reviewed for compatibility. The Medicaid 
payment system became operational statewide under the 
Texas Medicaid State plan in April 1989. As of the end of 
the Medicaid part in Fall 1992, over 102,000 Medicaid 
recipients had been a part of the demonstration. An 
evaluation database consisting of the Medicaid Client 
Assessment, Review, and Evaluation claims documents 
for the 102,000 recipients with at least three assessments 
was used for the evaluation. Medicare waivers were 
approved, and the Medicare pilot test was implemented in 
three Austin-area nursing homes in November 1 992 for a 
period of 18 months. At the time of their 1991 Federal 
certification survey, the pilot-tested facilities had 
59 Medicare Part A-covered residents. Cost analyses of 
both national and State samples of Medicare providers 
were performed to arrive at baseline costs for calculating 
the rates for the RUG-T18 groups. The resident 
assessment instrument, the minimum data set plus, that 
was developed for the multistate nursing home case-mix 
and quality (NHCMQ) demonstration was used for 
Medicare classification. In the Medicare pilot, a nurse 
reviewed weekly new admissions onsite to verify the 
classification of the residents into the RUG-T18 groups. 
The interrater reliability between the project nurse and the 
facility nurses was excellent. A paper, "Texas Medicare 
Case-Mix Pilot Study," which describes the pilot test and 
the data reliability processes, was presented at the 
National Case-Mix Conference in Maine in 1993. The 
lessons learned from this pilot will be used in 
implementing the NHCMQ demonstration. The final 
report of this project has been received and accepted. 

90-023 United Mine Workers of 
America Demonstration 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: Donald E. Pierce 



95-C-99643/3 
July 1990-December 1996 
Waiver only 
Cooperative Agreement 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



85 



Awardee: UMWA Health and Retirement Funds 

2021 K Street, NW. 

Washington, DC 20006 
HCFA Project Ronald W. Lambert 
Officer: Division of Delivery Systems and 

Financing 

Description: The United Mine Workers of America 
(UMWA) Health and Retirement Funds (the Funds) is a 
waiver-only demonstration that provides a risk-based 
Part B capitated payment for the Funds' Medicare-eligible 
retirees and dependents. The capitated payment replaces 
the Funds' cost-based, health care, prepayment plan 
arrangement. Approximately 80,000 Medicare eligibles 
are currently covered by the demonstration. This 
demonstration affords the Health Care Financing 
Administration (HCFA) the opportunity to test the ability 
of a large multi-employer trust to administer and contain 
costs under a risk-based Medicare Part B capitation 
arrangement. 

Status: The UMWA demonstration began on July 1, 1990, 
and is in its seventh year of operation. The demonstration 
has been extended through December 31, 1996, so that 
HCFA can consider the Funds' proposal for a new 
demonstration to include Part A. The proposed new 
payment arrangement involves equal risk sharing between 
the Funds and HCFA for Part A services. If approved, the 
new demonstration would be effective January 1, 1997. 

93-045 Update and Revision of the Continuous 
Update Diagnostic-Cost-Group Model 

Project No.: 500-92-0020DO06 

Period: June 1 993-December 1995 

Funding: $ 589,692 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Randall Ellis 

Awardee: Health Economics Research, Inc. 

(See page 193) 
HCFA Project Melvin J. Ingber, Ph.D. 
Officer: Division of Delivery Systems and 

Financing 

Description: This project is to continue the development 
of a patient-classification scheme to help determine 
capitated rates for Medicare health maintenance 
organization enrollees based on expected medical costs of 
enrollees. The system can be used for risk assessment of 
enrollees in health plans and for risk adjustment of 
payments to the plans. 

The system is a major revision of diagnostic-cost groups. 
Codes from the International Classification of Diseases, 
9th Revision. Clinical Modification for diagnoses are 
classified into clinically meaningful groups that have 



similar cost implications for the year following a 
12-month data collection period. Persons are 
characterized by their vector of disease classes. 
Regression analysis is used to determine the future cost 
implications of each class and demographic variable. The 
estimated structure is then used to assign scores, 
proportional to expected costs, to persons. 

A number of models have been evaluated (e.g., that ignore 
source of diagnosis, that use source of diagnosis in the 
model, that use a select list of procedures as an indicator). 
The principal paradigm is one of hierarchical coexisting 
conditions. In the model, a person may be coded for many 
classes of diseases, but for classes of disease that are split 
into subclasses by cost implications, the most serious 
condition subclass is used rather than the subclasses for 
the related lesser diagnoses. A hierarchy also is used in 
modeling with procedures. 

In addition to annually updated models, a monthly 
updated version was estimated. Medicare fee-for-service 
data from 1991 and 1992 were used for development. 

Validation measures were computed, including R-squares 
and ratios of predicted to actual costs for randomly 
selected and groups of special characteristics such as age- 
gender groups, people in first-year cost quintiles, and 
people with specific diseases. The system development 
and validation were done on the same data set used for 
identifier 93-046. 

Status: This project is complete. A report of the findings 
was published in the Health Care Financing Review, 
Volume 17, Number 3, Spring 1996. 

94-020 Use of Health Status Measures from the 
Medicare Current Beneficiary Survey to Improve 
the Adjusted Average Per Capita Cost 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



HCFA-94-0808 
July 1994-June 1995 
$ 25,000 
Contract 

Leonard Gruenberg, Ph.D. 

DataChron Health Systems 

763 Massachusetts Avenue, Suite 7 

Cambridge,, MA 02139 

Renee Mentnech 

Division of Delivery Systems and 

Financing 



Description: The purpose of this project is to use the 
health status measures from the Medicare Current 
Beneficiary Survey to improve the adjusted average per 
capita cost (AAPCC) method of paying health 
maintenance organizations. Various health status 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



86 



adjusters will be compared. Both the combined and 
independent effects on future use and expenditures of self- 
reported health status, disability status, diagnostic-cost- 
group category, and the AAPCC factors will be examined. 

Status: The analyses have been completed. 
Intramural 

IM-040 A Comparative Analysis of Formulas Used 
by Medicaid and Private Payers to Reimburse 
Pharmacists for Outpatient Prescription Drugs 

Funding: Intramural 

HCFA Project Kathleen Gondek, Ph.D. 

Director: Division of Payment Systems 

Description: The objective of this study was to compare 
and contrast insurance plan characteristics and payment 
formulas used by Medicaid and private third-party payers 
to reimburse pharmacies for outpatient prescription drugs. 
Information obtained included the geographic area served, 
total number of enrollees, cost-containment provisions, 
claims processing methods, and payment formulas. A 
market basket of 25 drugs was randomly selected from the 
top 100 drugs by dollar rank from Medispan for the last 
quarter of 1993 to illustrate the impact of payment 
formulas on reimbursement. The payment formulas used 
by a total of 95 plans (45 private and 50 Medicaid) were 
examined. The plans were ranked on the generosity of 
their formulas. 

Status: A paper is currently under review for publication. 
IM-069 Graduate Medical Education Studies 

Funding: Intramural 

HCFA Project Teresa DeCaro 

Director: Division of Payment Systems 

Description: Medicare and Medicaid financing of 
graduate medical education (GME) and its impact on the 
Medicare program, teaching institutions, and service- 
delivery systems is being explored. Several alternative 
demonstration designs are under review which could meet 
the following goals: reduce the number of full-time- 
equivalent interns and residents, increase the relative 
number of primary-care residencies, redirect training 
opportunities toward ambulatory and managed-care 
systems of care, and develop consortia that facilitate the 
necessary activities to achieve these goals. 

Status: The Health Care Financing Administration has 
been discussing the merits of various unsolicited 
proposals, and providing some direction for two 
promising concepts from New York and Utah. Among 
other features, the New York proposal seeks to 



significantly reduce the number of interns and residents in 
participating programs, assuming a 5 year phase-out of 
transition payments. The Utah proposal seeks to develop a 
State-mandated all-payer GME consortium responsible for 
workforce planning and the allocation of funded GME 
residency slots. GME funds would flow directly to and be 
allocated by the consortium. 

IM-008 Malpractice Component of the 
Medicare Economic Index 

Funding: Intramural 

HCFA Project Benson L. Dutton 

Director: Division of Payment Systems 

Mandate: Social Security Amendments of 1972 

(Public Law 92-603) 

Description: Each year since 1975, the Health Care 
Financing Administration (HCFA) has published the 
Medicare Economic Index (MEI), which was first 
mandated by Congress in Public Law 92-603 for use in 
establishing reasonable charges for physician services. 
Since 1992, the MEI has been used as a key factor in 
determining the Medicare fee schedule's annual 
conversion factor update pursuant to section 6102(a) of 
Public Law 101-239. The MEI is developed by HCFA's 
Office of the Actuary in accordance with the basic 
methodology set forth in 42 Code of Federal Regulations 
405.504(a)(3)(I) and 405.504(d) from selected 
components of the Consumer Price Index and the 
Producer Price Index, plus estimates of the annual 
changes in medical malpractice premiums for specific 
levels of coverage. HCFA's Office of Research and 
Demonstrations collects data from major medical 
malpractice insurers for calculating the annual 
malpractice component of the MEI. For several periods 
beginning January 1, 1987, the MEI increase has been 
established by Congress through section 9331(c)(1) of 
Public Law 99-509 for fee screen year (FSY) 1987, 
section 4041(a) of Public Law 100-203 for the first 
3 months of FSY 1988, section 4042(b)(4)(F)(iii) for FSY 
1989, and section 4105(a) of Public Law 101-508 for FSY 
1991 and FSY 1992. Again, for FSY 1994 and FSY 1995, 
changes in the physician-fee-schedule conversion factor 
and the Medicare volume-performance-standards update 
factor were established under sections 1351 1 and 13512 of 
Public Law 103-66, respectively. 

Status: The requisite data for updating the medical 
malpractice component of the MEI have been obtained 
and results provided to HCFA's Office of the Actuary. 
Announcement of the next MEI will be published in the 
Federal Register for FSY 1997 (January 1, 1997 to 
December 31, 1997). 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



87 



IM-066 Medical Savings Accounts for 
Medicare Beneficiaries 

Funding: Intramural 

HCFA Project Michael Kendix, Ph.D. 
Director: Division of Health Information and 

Outcomes 

Description: Medical savings accounts (MSAs) have been 
proposed as an insurance mechanism that will reduce the 
growth of expenditure on health services, by reducing the 
moral hazard effect associated with so-called first-dollar 
coverage. Countervailing this effect is the tendency of 
certain groups of beneficiaries to select into MSA, which 
may result in higher Medicare program expenditures, 
compared to fee for service. A typical MSA has two 
components — first, a catastrophic plan that covers 
expenditures above a fixed dollar value; second, a MSA 
component consisting of; funds held by the insured to be 
used to cover the first dollar amounts of expenditures. The 
objective of the project is to simulate the effect on 
Medicare program reimbursement of allowing 
beneficiaries to choose an MSA. The study uses 
longitudinal data from the Continuous Medicare History 
Sample a sub-sample of Medicare beneficiaries, 
reimbursement and expenditure. The project is attempting 
to calculate and simulate the long-term effects of allowing 
Medicare beneficiaries to choose an MSA as an 
alternative to fee-for-service or managed care. 

Status: The project is in its initial phase. 
IM-058 Outlier Pool Demonstration 

Award: Intramural 

HCFA Project Ronald W. Lambert 
Officer: Division of Delivery Systems and 

Financing 

Description: This is to be a demonstration to test an 
outlier pool payment approach. Three Medicare health 
maintenance organizations in the Seattle area (Group 
Health Cooperative of Puget Sound, PacifiCare, and 
Sisters of Providence) are potential participants. Plans 
will be paid at a rate of 97 percent of the adjusted average 
per capita cost, with 2 percent of the payments going into 
a pool. Plans with a higher-than-average incidence of 
high-cost cases will receive more from the pool than they 
paid in, and those with a lower incidence will receive less. 
Plans will be required to submit encounter data on all of 
their risk enrollees. In addition to serving as the basis for 
determining the costs of high-cost cases, these data will 
be used in the evaluation of the demonstration. 



Status: In April 1996, the Health Care Financing 
Administration (HCFA) and the plans reached agreement 
on the data specifications and the minimum requirements 
for the data set. Before the demonstration begins, each 
plan must submit a sample of encounter data that meets 
HCFA's requirements. As of September 30, 1996, no 
plans had met the sample data requirements. 

IM-041 Physician Practices' Responses 
to Changes in Fees 

Funding: Intramural 

HCFA Project Edgar A. Peden, Ph.D. and 

Directors: Jesse M. Levy, Ph.D. 

Division of Payment Systems 

Description: This project is being done to support the 
work of developing practice-cost relative-value units 
(RVUs) for Medicare. Currently the project includes three 
studies. The first examines physician practices' volume 
responses to overall changes in fees. Most studies up to 
now have viewed these responses in a short-run manner 
wherein physician practices increase the volume of 
services to make up for lost income when fees decrease, 
and decrease the volume of services when fees increase. 
This study posits that this phenomenon may be strictly 
short-run and that the volume, after the initial change, 
will revert to the level it would have been without the fee 
changes. Data from the American Medical Association 
(AMA) are then used to test this hypothesis. The second 
study investigates whether physicians' practice costs are a 
function of the fees they receive. Up to now, the proposed 
approaches to reimbursing practice costs for the Medicare 
program have centered around measuring and covering 
current costs on a procedure-by-procedure basis. This 
study shows that if fees themselves affect practice costs, 
this should be taken into account in setting fees that are 
both efficient (lowest cost) but that cover the practice 
costs that the practices adapt to rather than simply the 
current average costs. Again, the AMA data are being 
used to study the effect of fees on practice costs. The third 
study will incorporate what is found in the above two 
studies together with data from the Abt study, Data 
Collection and Analysis for Generating Procedure 
Specific Practice Expense Estimates (contract number 
500-95-0009), to develop alternative RVUs for 
physicians' practice costs on a procedure-by-procedure 
basis. This will include a scenario for setting RVUs based 
on an accounting methodology and a scenario which 
brings into play efficiency criteria. 

Status: The first and second studies are currently being 
prepared; the third study is in an early formative stage. 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



IM-024 Rehabilitation Facilities and Units: 
Utilization, Cost, and Payment 



Funding: 



Intramural 



HCFA Project William Buczko, Ph.D. 
Director: Division of Payment Systems 

Description: This project is examining use and financial 
trends in the Medicare prospective payment system (PPS)- 
excluded freestanding facilities and units in inpatient 
hospitals. Issues related to the creation of a PPS for 
inpatient rehabilitation providers also are examined. 

Status: This project has been examining Medicare 
provider analysis and review (MedPAR) and Hospital 
Cost Report Information System data to develop a 
description of the utilization and cost trends in PPS- 
excluded rehabilitation facilities and units. This project 
has examined issues related to the development of a 
system for measuring case-mix variation in inpatient 
rehabilitation populations and other issues related to the 
creation of a PPS for reimbursement of Medicare inpatient 
rehabilitation care. These activities will continue into 
fiscal year 1997. Papers using analyses from this project 
have been presented at the 1995 Annual Meeting of the 
American Public Health Association. 



IM-062 VA Capitation Workgroup 

Award: Intramural 

HCFA Project Ronald W. Lambert 
Officer: Division of Delivery Systems and 

Financing 

Description: This was a joint effort between the 
Department of Veterans Affairs (VA), the Health Care 
Financing Administration, and the Office of Management 
and Budget (OMB) to study the concept of the VA as a 
Medicare at-risk managed-care provider. This study was 
meant to outline the options, parameters, and associated 
costs of piloting the VA as a capitated Medicare provider 
to eligible veterans who currently do not have access to 
VA medical care because of funding restrictions. 

Status: A capitation workgroup was established jointly by 
the three agencies in August 1995. In June 1996, the 
workgroup completed its report on the design of the 
demonstration. The report addressed the requirements 
that the VA must meet, the waivers/legislation needed, 
and the payment methodology to be used if the project 
were implemented. This report was the basis of legislation 
proposed by the VA in August 1996 for a capitation 
demonstration. 



Theme 2: Improving Health Care Financing and Delivery Mechanisms 



89 



Theme 3: Meeting the Needs of Vulnerable Populations 



Extramural 

95-068 A Better Chance Welfare Reform Project 



96-044 Achieving Change for Texans 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00056/3 

October 1995-October 2002 

Waiver-only Project 

Elaine Archangelo 

Delaware Health and Social Services 

1901 North DuPont Highway 

Newcastle, DE 19720 

Alisa Adamo 

Office of State Health Care Reform 

Demonstrations 



Description: This demonstration is designed to test a set 
of provisions that will link opportunity and responsibility, 
support the formation and maintenance of two-parent 
families, provide positive incentives for private sector 
employment, and reduce teenage pregnancy. It also 
institutes the de-velopment of a Contract for Mutual 
Responsibility for all recipient families, which will 
address requirements such as school attendance for 
children, immunizations, etc. 

Some of the specific provisions in the demonstration are: 
a 2-year time limit for most families to move to economic 
self-sufficiency; the provision of Aid to Families with 
Dependent Children (AFDC) benefits after 2 years 
through a pay-after-performance work experience 
component; a requirement for weekly job search during 
the second 2-year period; and stronger sanctions for non- 
compliance with education- and employment-related 
provisions of the contract, which result in progressive 
reductions in AFDC benefits and potentially, a whole- 
family sanction. 

To reinforce these work and education requirements, the 
State is providing some additional benefits, such as an 
additional year of transitional Medicaid and transitional 
child care. Medicaid waivers were required to provide 
demonstration recipients 12 additional months of 
transitional Medicaid if their income is under 100 percent 
of the Federal poverty level. 

Status: The State began operations on October 1, 1995. 
With the August 22, 1996 enactment of the Personal 
Responsibility and Work Opportunity Reconciliation Act 
of 1996 (PRWORA), it is anticipated that the Title IV-A 
component of this demonstration will be modified. 
However, the impact of the PRWORA is being analyzed. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00080/6 

April 1996-April 2002 

Waiver-only Project 

Terry Trimble 

Texas Department of Human Services 

P. O. Box 14930 

Austin, TX 78714 

Alisa Adamo 

Office of State Health Reform 

Demonstrations 



Description: The demonstration contains a wide range of 
innovative welfare reform initiatives. Under the 
demonstration, Aid to Families with Dependent Children 
(AFDC) recipients must sign a Personal Responsibility 
Agreement. The Agreement requires them to attend 
school if they are under 19 years of age, cooperate with 
support collection and paternity establishment efforts, 
abstain from using drugs and abusing alcohol, provide 
health checkups and immunizations for their children and 
ensure that their children attend school. 

The agreement also requires recipients to participate in an 
activity that helps them become independent, such as an 
education, training, or literacy program, volunteer 
service, or community work. They may also be required to 
attend parenting classes. There are sanctions for failure to 
comply. 

The demonstration sets variable time limits for adult 
recipients' AFDC benefits, based on the education level 
and work experience of the adult recipients. The 
demonstration includes exemptions for those who cannot 
work and extensions for severe personal hardship for 
those who live in economically distressed areas. Families 
will retain Medicaid benefits if AFDC is terminated upon 
reaching the time limit. 

Certain AFDC recipients who are exempt from the Jobs 
Opportunity and Basic Skills (JOBS) program (i.e., 
individuals who have a child under 5 years of age or who 
have a disabled child) but who voluntarily participate in 
the program are entitled to 1 8 months of transitional 
Medicaid once they have worked their way off of welfare. 
Normally, AFDC recipients are entitled to 12 months of 
transitional Medicaid. The additional 6 months of 
transitional Medicaid is meant to be an incentive for 
exempt cases to voluntarily participate in the JOBS 
program. The Health Care Financing Administration's 
waiver authority was needed in order to implement this 
component of the demonstration. 



Theme 3: Meeting the Needs of Vulnerable Populations 



91 



Status: The project began operations in April 1996. With 
the August 22, 1996 enactment of the Personal 
Responsibility and Work Opportunity Reconciliation Act 
of 1996 (PRWORA), it is anticipated that the Title IV-A 
component of this demonstration will be modified. 
However, the impact of the PRWORA is being analyzed. 

94-086 Acute and Long-Term Care: 
Use, Costs, and Consequences 



96-045 Alabama Better Access for You (BAY) Health 
Plan Demonstration Project for Mobile County 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



17-C-90323/3 

September 1994-August 1997 

$ 595,787 

Cooperative Agreement 

Korbin Liu, Ph.D. 

Urban Institute 

2100 M Street, NW. 

Washington, DC 20037 

Carolyn Rimes 

Division of Aging and Disability 



Description: This study will provide current information 
that will aid policymakers in developing options to better 
integrate acute, subacute, and long-term-care services. 
Data from the Medicare Current Beneficiary Survey will 
be used to address three issues: transitions among acute, 
subacute, and long-term care; catastrophic costs resulting 
from the use of those services; and interactions between 
Medicare and Medicaid home health care. The transitions 
analysis is designed to measure differences in the patterns 
of acute, subacute, and long-term-care use by the 
characteristics of Medicare beneficiaries, and to determine 
potential areas of access or quality of care problems. The 
cost analysis is designed to assess the cumulative risks 
over 3 years of incurring catastrophic health care costs or 
experiencing Medicaid spenddown. The effects of the 
qualified Medicare beneficiaries program will be 
evaluated. The home health care analysis is designed to 
estimate the interactions and possible overlaps between 
two rapidly expanding public programs that finance 
similar services. The relationship between home health 
care use and costs and the personal characteristics of 
Medicare beneficiaries and the characteristics of 
geographic areas, including Medicaid policies, will be 
examined. 

Status: The first part of this project is complete. A final 
report. "Interactions between the Medicare and Medicaid 
Home Care Programs: Insights from States," has been 
produced and is available from Genevieve Kenny at the 
Urban Institute (202-857-8568). For the second phase, 
this project was dependent on the Medicare Current 
Beneficiary Survey's Cost and Use File. The file has been 
released, and the agency is in the data cleaning and 
analysis phase. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer 



ll-W-0085/4 

December 1 996-October 200 1 

Waiver-only Project 

Gwendolyn H. Williams 
Alabama Medicaid Agency 
501 Dexter Avenue 
P. O. Box 5624 

Montgomery, AL 36103-5624 
Maria Boulmetis 
Office of State Health Reform 
Demonstrations 



Description: The State of Alabama has proposed to set up 
a managed-care delivery system in Mobile County 
composed of a private-public partnership that will enroll 
all Medicaid beneficiaries into a managed-care network 
called the BAY Health Network. The network will be 
administered by the PrimeHealth Organization, a Health 
Maintenance Organization based in Mobile. Those 
eligible to participate under the demonstration are current 
Medicaid eligibles that include Aid to Families with 
Dependent Children (AFDC), low-income children, low- 
income adults, infants of SSI mothers, Aged, Blind, 
Disabled. There will be an extension of family planning 
benefits of up to 24 months for post-partum women below 
133 percent of poverty. All eligibles, except SOBRA 
women, will be guaranteed six months of Medicaid 
eligibility for HMO-covered services only. The benefit 
package will be the current mandated Medicaid benefits. 
The provider network will consist of the traditional 
Medicaid providers, but there will be opportunities for any 
willing provider to participate within the network if they 
meet the credential requirements specified within the 
managed-care contract. Beneficiaries may change 
providers within the network at any time and without 
cause, except in cases of documented abuse. There will be 
no cost sharing for Medicaid beneficiaries under the 
demonstration. 

Status: The State proposes to implement the 
demonstration in March 1997. 

82-001 Arizona Health Care Cost-Containment System 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



ll-W-00032/9-13 
June 1982— September 
Waiver-only Project 



997 



John H. Kelly 
Arizona Health Care 
Cost-Containment System (AHCCCS) 
80 1 East Jefferson 
Phoenix, AZ 85034 



92 



Theme 3: Meeting the Needs of Vulnerable Populations 



HCFA Project Joan Peterson, Ph.D. 
Officer: Office of State Health Reform 

Demonstrations 

Description: This project is designed to test the 
effectiveness of establishing, under Title XIX of the 
Social Security Act, a Medicaid program based on 
competitive principles, including primary care physicians 
acting as gatekeepers, prepaid capitated contracts, 
competitive bidding, use of nominal copayments, and 
limited restrictions on freedom of choice. Acute-care 
services are provided by health plans and long-term-care 
(LTC) services are provided through capitated contracts 
by the State with five Arizona counties and two private 
LTC contractors. In addition, capitated behavioral health 
services are provided to acute-care and long-term-care 
enrollees. 

Status: The Arizona Health Care Cost Containment 
System (AHCCCS) began operation on October 1, 1982, 
and initially covered only acute-care services. The 
Arizona Long-Term Care System (ALTCS) component 
was approved as part of a 5-year extension of the 
AHCCCS demonstration from October 1, 1988, through 
September 30, 1993. The phase-in of comprehensive 
behavioral health services began on October 1, 1990, and 
was completed on October 1, 1995. On January 6, 1993, 
the Health Care Financing Administration (HCFA) 
granted a 1-year extension to the demonstration. On 
August 16, 1994, HCFA approved an additional 3-year 
extension of the waivers through September 30, 1997. 

95-047 Arizona Welfare Reform: Employing and 
Moving People Off Welfare and Encouraging 
Responsibility Program (EMPOWER) 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00058/7 

May 1995-October2002 

Waiver-only Project 

Linda Blessing 

Arizona Department of 

Economic Security 

P.O. Box 6123 

Phoenix, AZ 85005 

Joan Peterson, Ph.D. 

Office of State Health Reform 

Demonstrations 



Description: Statewide, the demonstration will not 
increase benefits for additional children conceived while 
the mother is receiving Aid to Families with Dependent 
Children (AFDC); will limit benefits to adults to 
24 months in any 60-month period; will allow recipients 
to deposit up to $200 per month (with 50 percent 
disregarded) in Individual Development Accounts; will 



require minor mothers to live with parents; will extend 
transitional child care and Medicaid to 24 months; and 
will eliminate the 100-hour rule for Aid to Families with 
Dependent Children-Unemployed Parent cases. In a pilot 
site, the demonstration will provide individuals with 
short-term public or private on-the-job training subsidized 
by grant diversion, which includes cashing-out food 
stamps. 

Status: This project was implemented on 
November 1, 1995. The State began to submit quarterly 
reports on program progress and cost neutrality with the 
quarter ending December 1, 1995. An evaluation contract 
was awarded to Abt Associates on June 1, 1996. Abt 
Associates submitted an evaluation plan in late 
August 1996. With the August 22, 1996 enactment of the 
Personal Responsibility and Work Opportunity 
Reconciliation Act of 1996 (PRWORA), it is anticipated 
that the Title IV-A component of this demonstration will 
be modified. However, the impact of the PRWORA is 
being analyzed. 

94-052 Availability and Effective Use of 
Pediatric and Family Nurse Practitioners 
Under State Medicaid Programs 

Project No.: 18-C-903 10/4-01 

Period: September 1994-December 1995 

Funding: $ 152,002 

Award: Cooperative Agreement 

Principal 

Investigator: Dale C. Jones, Ph.D. 

Awardee: Research Triangle Institute 

3040 Cornwallis Road 
Research Triangle Park, NC 27709 

HCFA Project Penelope L. Pine 

Officer: Division of Health Information and 

Outcomes 

Description: The primary objectives of this study are to 
assess the availability of family and pediatric nurse 
practitioners to provide services to the Medicaid 
population and to describe the extent to which nurse 
practitioners are currently caring for Medicaid patients. 
The main sources of data will be two national surveys of 
advanced practice nurses, conducted in the early 1990s. 

Status: There are four studies that have been completed 
for this project. Three of these papers are concerned with 
defining and describing the role of advanced practice 
nurses (APNs). The fourth paper addresses the issue of 
how the competence of APNs can be ensured in 
developing a mechanism for reimbursing APNs. 



Theme 3: Meeting the Needs of Vulnerable Populations 



93 



93-005 California Welfare Reform: Assistance 
Payments Demonstration Project (Formerly, 
California Assistance Payment Demonstration) 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00018/9 

October 1992-March 1999 

Waiver-only Project 

Eloise Anderson 
California Department of 
Health Services 
714/744 P Street 
Sacramento, CA 95814 
Joan Peterson, Ph.D. 
Office of State Health Reform 
Demonstrations 



Description: This demonstration originally had waivers 
from the Administration for Children and Families (ACF) 
that removed the time limitation on the disregard of 
earnings of recipients of Aid to Families with Dependent 
Children (AFDC) and removed the limitation on hours of 
work in two-parent families in California. Subsequent 
ACF waivers were added, permitting the State to give 
teenage parents bonuses/penalties in the AFDC grant 
payment for grade averages above/below certain levels; 
increasing resource limitations and disregarding restricted 
savings accounts; implementing certain changes in the 
Job Opportunities and Basic Skills program required 
under Federal law; and allowing recipients with earned 
income to choose child-care assistance in lieu of a cash 
grant. In conjunction with this demonstration, the State 
decreased the welfare payment. The Health Care 
Financing Administration (HCFA) granted a maintenance 
of effort waiver, permitting the approval of State 
Medicaid plans, even though the AFDC payment level 
was below the level in effect on May 1, 1988. HCFA also 
authorized the State to maintain the eligibility level of its 
medically needy program, making the medically needy 
eligibility level more than 133 1/3 percent of the lowered 
AFDC payment level. The reduction in AFDC benefits 
was contested, and the Ninth Circuit Court of Appeals 
vacated HCFA's "maintenance of effort" waiver (Beno v. 
Shalala). In July 1 994, the court remanded the case to the 
Secretary of the Department of Health and Human 
Services for additional consideration. 

Status: As part of the court's decision in Beno v. Shalala, 
the Department was required to reconsider the vacated 
Medicaid "maintenance of effort" waiver at a future date. 
As a result, amendments were approved in February 1996 
to exempt certain categories of AFDC families from the 
State's benefit cuts, paying the exempt cases based on 
grant levels in effect in California on November 1, 1992. 
In addition, the waiver of the Medicaid "maintenance of 
effort" provision was reinstated. With the August 22, 
1996 enactment of the Personal Responsibility and Work 



Opportunity Reconciliation Act of 1996 (PRWORA), it is 
anticipated that the Title IV-A component of this 
demonstration will be modified. However, the impact of 
the PRWORA is being analyzed. 

96-065 California Welfare Reform: 
California Work Pays Demonstration Project 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00018/9 

September 1995-June 1999 

Waiver-only Project 

Eloise Anderson 
California Department of 
Social Services 
744 P Street 
Sacramento, C A 95814 
Joan Peterson, Ph.D. 
Office of State Health Reform 
Demonstrations 



Description: The original portion of the demonstration, 
Incentives to Self-Sufficiency, consists of four provisions: 
a 100-hour Community Work Experience (CWEP) 
requirement, transitional child care, fraud prevention, and 
transitional Medicaid. Specifically, a 12-month Medicaid 
transition benefit is provided to cases in the treatment 
group that lose Aid to Families with Dependent Children 
(AFDC) eligibility (and thereby, Medicaid eligibility) due 
to increased income or increased assets resulting from 
marriage or the reuniting of spouses. The demonstration 
was amended in August 1996 to implement the maximum 
family grant, which prevents increases in the AFDC 
payment to families on account of any child born to the 
family if they received AFDC for 10 continuous months 
prior to the birth of the child. 

Status: The State continues to operate this demonstration 
project. With the August 22, 1996 enactment of the 
Personal Responsibility and Work Opportunity 
Reconciliation Act of 1996 (PRWORA), it is anticipated 
that the Title IV-A component of this demonstration will 
be modified. However, the impact of the PRWORA is 
being analyzed. 

93-090 Catastrophic Costs and Medicaid Spenddown 

(Formerly Long-Term Case Studies (Section 207) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



500-89-0047/37 
January 1993-May 1995 
$ 180,300 
Contract 

David Kennell 
Lewin/VHI, Inc. 
(See page 17) 



94 



Theme 3: Meeting the Needs of Vulnerable Populations 



HCFA Project Carolyn Rimes 

Officer: Division of Aging and Disability 

Description: This study uses data from the Medicare 
Current Beneficiary Survey (MCBS) to analyze the 
occurrence of catastrophic costs among the elderly 
resulting from Medicaid spenddown. The purpose of this 
study is to support the formulation of policy for health 
care reform for the elderly. Consequently, this study 
categorizes the causes of out-of-pocket costs for different 
types of acute and long-term-care services that may create 
financial hardships and identifies which subgroups of the 
elderly are likely to incur catastrophic costs. This work 
will be completed by the Urban Institute under 
subcontract to Lewin VHI, Inc. 

Status: Preliminary analyses have been completed. The 
final report is expected in January 1997. 

94-077 Changes in Population Characteristics and 
Medicaid Utilization Expenditures Among Children 
and Adolescent Supplemental Security Income 
Recipients 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-90455/1 

September 1 994-September 1997 

S 642,035 

Cooperative Agreement 

James Perrin, M.D. 
Massachusetts General Hospital 
Children's Service 
Fruit Street. WACC715 

Boston. MA 021 14 
Feather Ann Davis. Ph.D. 
Division of Asina and Disabilitv 



Description: The Supplemental Security Income (SSI) 
program for children and adolescents has expanded in the 
past 5 years as a result of new Social Security 
Administration (SSA) guidelines for determining 
disability caused by mental impairments, new guidelines 
for determining childhood disability in general, and major 
outreach efforts by SSA to identify children with 
disabilities. The project has four main objectives: 

• Determine the current clinical characteristics of child 
and adolescent SSI recipients and the changes in these 
characteristics during the period of program expansion 
that began in the late 1980s. 

• Determine patterns of Medicaid utilization and 
expenditures among important clinical subgroups and 
examine changes in these patterns during the period of 
program expansion. 



• Examine the utilization trajectories and clinical 
characteristics of certain SSI recipient groups over time. 
including recipients with high-cost physical conditions 
such as cystic fibrosis, congenital heart disease, and 
spina bifida, and high-prevalence, low-cost conditions 
such as attention deficit disorder, hyperactivity, and 
learning disabilities. 

• Determine the degree to which new recipients reflect 
shifting among Medicaid eligibility categories and the 
coverage and use of other insurance after getting SSI. 

Status: Data files construction is almost complete, and 
analyses on three of the six States are underway and 
three papers have been prepared: 

• "Secular Trends in Conditions Among Children 
Receiving SSI Benefits," which found that the number 
of SSI children in institutions increased minimally 

(3 percent), despite an 83-percent increase in SSI 
enrollment. The number of children with leukemia 
enrolled in SSI increased 33 percent, while those with 
other physical conditions increased over 70 percent; the 
number of children with mental retardation increased 
615. In contrast, the number of SSI children with 
asthma increased dramatically (185 percent), but at a 
rate similar to the 1 62-percent increase in asthma 
among the non-SSI Medicaid population. A four-fold 
increase in Attention Deficit Hyperactivity Disorder 
among SSI enrollees is comparable to the four-fold 
increase in the condition among the non-SSI Medicaid 
enrolled children. 

• "The SSI Children's Disability Program: New Entrants 
of AFDC Upgrades?" found that about half of the 
children newly receiving SSI benefits had previously 
received AFDC benefits and thus experienced a major 
increase in monthly cash benefits. The other half of new- 
SSI recipients were new to public insurance. 

• "The Supplemental Security Income Children's 
Disability Program: Impact of Program Growth on 
Population with High Expenditures." This preliminary 
analysis on only Georgia data found that the number of 
children with costs over S25,000 decreased very slightly 
from 4.3 percent of the SSI population in 1989 to 

4.1 percent in 1992. 

94-083 Changing Roles of Nursing Homes 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



17-C-90428/5 

September 1 994-January 1998 

S 831,182 

Cooperative Agreement 

Brant Fries, Ph.D. 

Institute of Gerontology 

University of Michigan 

300 North Ingalls Building, Room 900 

Ann Arbor, MI 48109-2007 



Theme 3: Meeting the Needs of Vulnerable Populations 



95 



HCFA Project Feather Ann Davis, Ph.D. 
Officer: Division of Aging and Disability 

Description: Although nursing homes have traditionally 
provided custodial care to the physically and cognitively 
impaired elderly, nursing homes are increasingly treating 
a more diverse and more clinically complex patient mix. 
Since the implementation of Medicare's prospective 
payment system for hospitals, growing numbers of 
nursing homes have begun caring for patients requiring 
"subacute" or post-acute care following a hospital stay. 
Between 1986 and 1993, the number of Medicare certified 
hospices in the United States grew from 355 to 1,445. 
From 1992 to 1995, the number of special care hospice 
units in nursing homes grew to 206, up 100 percent. 

This study examines two special nursing home 
populations: hospice patients and the chronically 
mentally ill (other than dementia). Several hypotheses 
regarding quality, use, and cost issues will be examined 
for both groups, such as that residents with chronic 
mental illness are more likely than are other similarly 
functionally impaired residents, to experience increasing 
functional impairment, to have increased behavior 
problems and to be chemically restrained. It is 
hypothesized that mentally ill patients will have greater 
overall use of Medicare services than will non-mentally 
impaired nursing home residents with similar levels of 
functional impairment. The study utilizes 1993 data on 
the entire nursing home populations of eight states 
(Kansas, Maine, Mississippi, Nebraska, New York, Ohio, 
Pennsylvania, South Dakota, and Washington), about 
250,000 residents, linked with the HCFA Survey and 
Certification Reports, the Medicare Part A and Part B 
claims files and the Area Resource File data. The 
Minimum Data Set for Nursing Home Resident 
Assessment and Care Screening is used to collect health 
status data on all residents in Medicaid-certified, 
Medicare-certified and dually certified nursing facilities. 
The hospice substudy will describe how nursing home 
hospice services are concentrated in particular regions, 
markets and facilities; compare rates of hospital use and 
costs of terminal care residents in nursing homes that do 
and do not use the Medicare hospice benefit; and describe 
the quality of life, including pain experience and 
analgesics prescribed among terminal cancer patients in 
nursing homes who are served by hospice care and those 
not so served. 

Status: A draft report, "Hospice in Nursing Homes," 
presents initial analyses of longitudinal files of 1991-95 
nursing home survey data merged with patient assessment 
data. Multivariate analyses indicate that hospice special 
care units are located in relatively small and medium size 
facilities with low occupancy, high technological capacity 
and a higher skill level of staffing mix. Also, nursing 



home characteristics such as being a proprietary facility, 
not part of a chain and being located in a competitive 
environment are significantly related to having a hospice 
special care unit. The authors note that the growth in 
special care hospice units in nursing homes reflects 
changes in reimbursement mechanisms, increases in the 
proportion of all deaths occurring in nursing homes, and 
by nursing home efforts to specialize. A paper, "Special 
Populations in Nursing Homes: Residents with Chronic 
Mental Illness or Developmental Disabilities," is being 
presented at the November 1 996 meeting of the 
Gerontological Society of America. 

94-071 Colorado Welfare Reform: Personal 
Responsibility and Employment Program 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00009/8 

November 1993-October 1997 

Waiver-only Project 

Barbara McDonnell 
Colorado Department of 
Social Services 
1575 Sherman Street 
Denver, CO 80203-1714 
Maria Boulmetis 
Office of State Health Reform 
Demonstrations 



Description: This demonstration has waivers from the 
Health Care Financing Administration, the 
Administration for Children and Families (ACF), and the 
Department of Agriculture (Food Stamps) to: 

• Consolidate the Aid to Families with Dependent 
Children (AFDC) grant, Food Stamps, and child-care 
benefits into a single cash payment. 

• Impose AFDC financial sanctions on families if 
children under 2 years of age are not immunized or 
employable adults are non-cooperative after 2 years. 

• Increase disregards of earnings and assets and provide 
financial incentives to participants who graduate from 
high school or who obtain a high school equivalency. 

• Allow cases that have been on AFDC for less than 3 of 
the previous 6 months to receive the Medicaid 
transition benefit, if they lose AFDC eligibility because 
of earnings, and eliminate quarterly-income reporting 
during the transition period, reporting only income 
increases. 

Status: The State is continuing to implement the 
demonstration. With the August 22, 1996 enactment of 
the Personal Responsibility and Work Opportunity 
Reconciliation Act of 1996 (PRWORA), it is anticipated 
that the Title IV-A component of the PRWORA is being 
analyzed. 



96 



Theme 3: Meeting the Needs of Vulnerable Populations 



92-070 Community Nursing Organization 
Demonstration: Carle Clinic Association 

(Formerly, Community Nursing Organization 
Demonstration) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



500-92-0053 

September 1 992-December 1996 

$ 1,786,629 

Contract 

Cheryl Schraeder, Ph.D. 

Carle Clinic Association 

307 East Oak, Suite 3 

P.O. Box 718 

Mahomet, IL 61853 

Thomas Theis 

Division of Aging and Disability 

Omnibus Budget Reconciliation Act of 
1987 (Public Law 100-203) 



Description: Section 4079 of Public Law 100-203 directs 
the Secretary of the Department of Health and Human 
Services to conduct demonstration projects at four or more 
sites to test a capitated, nurse-managed system of care. 
The two fundamental elements of the Community Nursing 
Organization (CNO) Demonstration are capitated pay- 
ment and nurse case management. These two elements are 
designed to promote timely and appropriate use of 
community health services and to reduce the use of costly 
acute-care services. The legislation mandates a CNO 
service package that includes home health care, durable 
medical equipment, and certain ambulatory care services. 
Four applicants were awarded site demonstration 
contracts on September 30, 1992. The selected sites 
represent a mix of urban and rural sites and different 
types of health providers, including a home health agency 
(HHA), a hospital-based system, and a large 
multispecialty clinic. The four sites are: 

• Carle Clinic Association, Mahomet, Illinois, one of the 
largest multispecialty physician group practices in the 
United States, functions as the regional medical center 
for the rural population of Central Illinois and Western 
Indiana and serves nearly 2,000 patients daily. 

• Carondelet Health Services, Inc., Tucson, Arizona, a 
group of three hospitals, a family center, and 

1 7 community health centers, is sponsored by the 
Sisters of St. Joseph of Carondelet. 

• Visiting Nurse Service of New York, New York, is the 
largest nonprofit Medicare-certified HHA in the 
United States. 

• Living at Home/Block Nurse Program, St. Paul, 
Minnesota, is a nursing organization dedicated to 
assisting communities in replicating the Living at 
Home/Block Nurse Program model of local volunteer 
and nursing support for the elderly. 



Status: All four CNO Demonstration sites have undergone 
a 1-year development period and began a 3-year 
operational period in January 1994, which continued in 
1996. Abt Associates was selected to evaluate the project 
and to provide technical assistance to the four CNO sites. 
Abt Associates also was awarded the external quality 
assurance contract. 

92-071 Community Nursing Organization 
Demonstration: Carondelet Health Services, Inc. 

(Formerly, Community Nursing Organization 
Demonstration) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



500-92-0055 

September 1 992— December 1996 

$ 878,413 

Contract 

Gerri Lamb, Ph.D. 

Carondelet Health Services, Inc. 

Carondelet St. Mary's Hospital 

1601 West St. Mary's Road 

Tucson, AZ 85745 

Thomas Theis 

Division of Aging and Disability 

Omnibus Budget Reconciliation Act 
of 1987 (Public Law 100-203) 



Description: The purpose of the Community Nursing 
Organization (CNO) demonstration is to develop and 
evaluate a nurse case-managed health care delivery 
system that provides Medicare-covered home health 
services, ambulatory care services, and durable medical 
equipment to eligible beneficiaries. Section 4079 of Public 
Law 100-203 directed the Secretary of the Department of 
Health and Human Services to conduct this demonstration 
at four or more sites. The authorizing legislation 
identified a package of mandatory services that each CNO 
has to provide. It also required that the demonstration 
have a capitated payment method modeled after the 
average adjusted per capita cost payment used with health 
maintenance organizations. Another provision of the 
legislation stipulated that an alternative capitation 
formula be implemented in at least one of the four sites. 
The participating organizations will assume full financial 
risk for the demonstration's mandatory service package. 
In addition to these services, Carondelet provides optional 
services such as homemaker/home health aide services 
and respite care. The project's evaluation will examine 
the feasibility and viability of a capitated nurse- 
coordinated service model. 

Status: On September 30, 1992, Carondelet Health 
Services was awarded one of four contracts to conduct the 
CNO demonstration. During the project's development 
year, the Carondelet Health Services established its 



Theme 3: Meeting the Needs of Vulnerable Populations 



97 



organizational protocol, marketing and enrollment plan, 
service delivery system, and data collection plan for 
implementation of the CNO demonstration. The 3-year 
operational phase of the demonstration began in 
January 1994 and continued in 1996. Abt Associates was 
selected to evaluate the project and to provide technical 
assistance to the four CNO sites. Abt Associates also was 
awarded the external quality assurance contract. 

92-073 Community Nursing Organization 
Demonstration: Visiting Nurse Service of 
New York (Formerly, Community Nursing 
Organization Demonstration) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



500-92-0054 

September 1992— December 1996 

$ 945,282 

Contract 

Ruth Mitchell 

Visiting Nurse Service of New York 

107 East 70th Street 

New York, NY 10021-5087 

Thomas Theis 

Division of Aging and Disability 

Omnibus Budget Reconciliation Act of 
1987 (Public Law 100-203) 



Description: Section 4079 of Public Law 100-203 directs 
the Secretary of the Department of Health and Human 
Services to conduct demonstration projects at four or more 
sites to test a capitated, nurse-managed system of care. 
The two fundamental elements of the Community Nursing 
Organization (CNO) demonstration are capitated payment 
and nurse case management. These two elements are 
designed to promote timely and appropriate use of 
community health services and reduce the use of costly 
acute-care services. The legislation mandates a CNO 
service package that includes home health care, durable 
medical equipment, and certain ambulatory care services. 
Four applicants were awarded site demonstration 
contracts on September 30, 1992. The selected sites 
represent a mix of urban and rural sites and different 
types of health providers, including a home health agency 
(HHA), a hospital-based system, and a large 
multispecialty clinic. The four sites are: 

• Visiting Nurse Service of New York, New York, is the 
largest nonprofit Medicare- certified HHA in the 
United States. 

• Living at Home/Block Nurse Program, St. Paul, 
Minnesota, is a nursing organization dedicated to 
assisting communities in replicating the Living at 
Home Block Nurse Program model of local volunteer 
and nursing support for the elderly. 



• Carle Clinic Association, Mahomet, Illinois, one of the 
largest multispecialty physician group practices in the 
United States, functions as the regional medical center 
for the rural population that resides in Central Illinois 
and Western Indiana and serves nearly 2,000 patients 
daily. 

• Carondelet Health Services, Inc., Tucson, Arizona, 
a group of three hospitals, a family center, and 

17 community health centers, is sponsored by the 
Sisters of St. Joseph of Carondelet. 

Status: All four CNO demonstration sites have undergone 
a 1-year development period and began a 3-year 
operational period in January 1994, which continued in 
1996. Abt Associates, Inc. was selected to evaluate the 
project and to provide technical assistance to the four 
CNO sites. Abt Associates, Inc. also was awarded the 
external quality assurance contract. 

93-077 Community-Supported Living Arrangements 
Program: Process Evaluation 

Project No.: 500-92-0035DO02 

Period: September 1993-March 1997 

Funding: $411,941 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Marilyn Ellwood 

Awardee: SysteMetrics/MedStat 

(See page 132) 

HCFA Project Samuel L. Brown 

Officer: Division of Aging and Disability 

Mandate: Section 4712 of the Omnibus Budget 

Reconciliation Act of 1990 
(Public Law 101-508) 

Description: The Community-Supported Living 
Arrangements (CSLA) Program is designed to test the 
effectiveness of developing, under section 1930 of the 
Social Security Act, a continuum of care concept as an 
alternative to the Medicaid-funded residential services 
provided to individuals with mental retardation and 
related conditions (MR/RC) as an optional State plan 
service. The CSLA program serves individuals with 
MR/RCs who are living in the community either 
independently, with their families, or in homes with three 
or fewer other individuals receiving CSLA services. This 
model of care includes personal assistance; training and 
habilitation services necessary to assist individuals in 
achieving increased integration, independence, and 
productivity; 24-hour emergency assistance; assistive 
technology; adaptive technology; support services 
necessary to aid these individuals in participating in 
community activities; and other services, as approved by 



98 



Theme 3: Meeting the Needs of Vulnerable Populations 



the Secretary of the Department of Health and Human 
Services. Costs related to room and board and to 
prevocational, vocational, and supported employment 
services are excluded from coverage. In accordance with 
the legislatively set maximum, California, Colorado, 
Florida, Illinois, Maryland, Michigan, Rhode Island, and 
Wisconsin have implemented CSLA programs. The 
purpose of this contract is to provide an evaluation of the 
CSLA program to the Health Care Financing 
Administration's Medicaid Bureau and Congress for their 
consideration of policy options regarding the continuation 
and/or expansion of the Medicaid State Plan optional 
service. The evaluation will address five areas: 

• Philosophy or goals guiding States' CSLA programs. 

• Description of CSLA programs with respect to 
recipients, types of services received, and the cost of 
such services. 

• Description and discussion of quality assurance 
mechanisms being implemented. 

• Exploration of the question of compatibility of the 
supported living concept with current goals and the 
structure of the Medicaid program. 

• Exploration of the relationship between the supported 
living concept and the Americans with Disabilities Act. 

Status: The contract was awarded on September 30, 1993. 
As of September 1996, the eight site visits to the 
participating States have been conducted. Six of the eight 
State case studies have been reviewed and are approved 
for distribution. Secondary data analysis will be conducted 
using data available from the participating CSLA States. 
A final evaluation report is expected in March 1997. 

92-058 Comparative Study of the Use of Early and 
Periodic Screening, Detection, and Treatment and 
Other Preventive and Curative Health Care Services 
by Children Enrolled in Medicaid 

Project No.: 500-92-0066 

Period: September 1992— January 1997 

Funding: $ 1,262,400 

Award: Contract 

Principal 

Investigator: Jeffrey Wasserman, Ph.D. 

Awardee: SysteMetrics, Division of MedStat, Inc. 

777 East Eisenhower Parkway 

Suite 500 

Ann Arbor, MI 48108 
HCFA Project Feather Ann Davis, Ph.D. 
Officer: Division of Aging and Disability 



Description: The contract comprises a series of research 
projects designed to: 

• Study the effect of the changes in the Early Periodic 
Screening, Diagnosis, and Treatment (EPSDT) 
Program introduced by the Omnibus Budget 
Reconciliation Act of 1989 on the process of providing 
health services to children and on the appropriateness 
of expenditures for the services provided in California, 
Georgia, Michigan, and Tennessee. 

• Compare Medicaid-enrolled children in four EPSDT 
programs with other Medicaid-enrolled children in the 
four States who are not receiving EPSDT services, 
regarding enrollment patterns, service utilization, and 
expenditures, with a particular emphasis on preventive 
health services. 

• Compare Medicaid-enrolled children with non- 
Medicaid-enrolled children, insured and uninsured, on 
the use of and expenditures for preventive services and 
other health care services, using national survey data. 

Status: The final report is under development. Reports 
received from this contractor include: 

• Gavin, N.: "The Impact of Medicaid on Children's 
Health Service Use and Expenditures: 1987 National 
Medical Expenditure Survey." October 12, 1995, 
revised August 12, 1996. 

• Gavin, N.: "The Impact of Medicaid on Children's 
Health Service Use: A Ten- Year Retrospective 
Analysis," March 1996. 

• Hill, I. and Zimmerman, B.: "Evaluation of EPSDT 
Programs in the Tape-To-Tape States: Volume I: 
Synthesis of EPSDT Case Study Reports," May 3, 1995. 

• Hill, I. and Zimmerman, B.: "Evaluation of EPSDT 
Programs in the Tape-to-Tape States: Volume II: 
Case Study Reports," May 3, 1995. 

• Hill, I. and Zimmerman, B.: "Evaluation of EPSDT 
Programs in the Tape-To-Tape States: Volume I: 
Synthesis of EPSDT Case Study Reports," May 3, 1995. 

• Hill, I. and Zimmerman, B.: "Evaluation of EPSDT 
Programs in the Tape-to-Tape States: Volume II: 
Case Study Reports," May 3, 1995. 

• Adams, E. K.., and Graver, L.: "Analysis of Medicaid 
Provider Supply Overall and for Preventive Care 
Services for Children, 1989," June 1994. 

• Gavin, N., and Bencio, D.S.: "Comparison of Access to 
Care Among Medicaid and Other Groups of Children: 
1982 and 1988 National Health Interview Surveys," 
November 23, 1993. 

• Gavin, N.: "Review and Synthesis of the Literature on 
the Implementation and Effectiveness of Recent 
Legislative Initiatives Relating to Medicaid and EPSDT 
Coverage for Children," December 15, 1992. 

• Herz, L., Gavin, N., Ellwood, M., and Sredl, K.: 
"The Use of EPSDT and Other Health Care Services 
by Medicaid Children, 1989," May 3, 1994. 



Theme 3: Meeting the Needs of Vulnerable Populations 



99 



95-025 Comparison of Income Information on 
1990 Census with Information Collected by the 
Current Beneficiary Survey 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



HCFA-95-0265 
March 1995-June 
$ 23,388 
Purchase Order 



1995 



A. Marshall McBean, M.D. 

University of Minnesota 

420 Delaware Street, SE. 

Minneapolis, MN 55455 

Leslye Fitterman, Ph.D. 

Division of Health Information and 

Outcomes 



Description: This study compared self-reported income as 
collected in the Medicare Current Beneficiary Survey 
(MCBS) with income in the Bureau of the Census Survey. 
The purpose was to determine the usefulness of socio- 
economic information from the Bureau of the Census to 
augment Medicare claims data to examine racial 
differences in access, utilization, and outcomes of care. 
A data file was constructed from the Bureau of the Census 
data that assigned age- and race-specific median 
household income to each Zip code. The age- and race- 
specific data were calculated using the distribution of age 
and race within the population 65 years of age and older 
in each Zip code. The MCBS data file contained income, 
age, race, and address. A computer program matched 
address and Zip code from the MCBS file to census tract 
and census-block group. The comparison between the two 
data sources was performed at three levels — Zip code, 
census tract, and census-block group. 

Status: Only 27 percent of beneficiaries, addresses were 
able to be mapped into census tracts. However, the study 
findings suggest that Zip code level median income 
derived from Bureau of the Census data for elderly 
persons was higher by age and racial subgroups than the 
MCBS survey information. The final report is available 
from the National Technical Information Service, 
accession number, PB97-1 1 1025. 

94-069 Connecticut Welfare Reform: Reach for 
Jobs First (Formerly, A Fair Chance) 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



ll-W-00022/1 

August 1994-July 1999 

Waiver-only Project 

Joyce A. Thomas 
Connecticut Department of 
Social Services 
25 Sigourney Street 
Hartford, CT 06106-5033 



HCFA Project Joan Peterson, Ph.D. 
Officer: Office of State Health Reform 

Demonstrations 

Description: In October 1994, Connecticut began 
implementing the reforms embodied in A Fair Chance, 
which had been approved in August 1994. Statewide, this 
demonstration expanded Aid to Families with Dependent 
Children-Unemployed Parent (AFDC-UP) program 
eligibility; changed filing unit requirements; increased 
motor vehicle and asset limits; eliminated the 185 percent 
of need test; disregarded student earnings; increased 
earned-income disregards; redirected support payments to 
the AFDC family; extended transitional child care and 
Medicaid benefits; and included several jobs program 
changes. In the pilot sites, the demonstration required 
work activity after 2 years of AFDC, eliminated most jobs 
exemptions, and established a child-support assurance 
program. Significant amendments to A Fair Chance were 
approved in December 1995, and the demonstration was 
renamed Reach for Jobs First. Statewide, the amendments 
establish time limits; disregard earnings for time-limited 
recipients up to the poverty level; reduce the benefit 
increase for additional children by one-half; require minor 
parents to live with an adult; change redetermination, 
verification, and reporting requirements; provide 
employer tax credits for hiring AFDC recipients; require 
biometric identification as a condition of eligibility; 
establish a two-tier payment system for new residents; 
simplify and conform AFDC and Food Stamp rules on 
resources; change Jobs Opportunity and Basic Skills 
(JOBS) sanctions; extend transitional Medicaid to 2 years; 
and establish the several other provisions. In addition, 
Connecticut received permission from Health Care 
Financing Administration to maintain their medically 
needy income level at the pre-July 1995 level despite a 
reduction in the AFDC payment standard. 

Status: The Reach for Jobs First amendments were 
implemented on January 1, 1996. With the 
August 22, 1996 enactment of the Personal Responsibility 
and Work Opportunity Reconciliation Act of 1996 
(PRWORA), it is anticipated that the Title IV-A 
component of this demonstration will be modified. 
However, the impact of the PRWORA is being analyzed. 

91-088 Coordinating Care for Pregnant Substance 
Abusers Demonstration: Maryland 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 



ll-C-06 103/5 

September 1991-December 1996 

$ 1,300,000 

Cooperative Agreement 

Mary E. Stuart, Sc.D., Director 



100 



Theme 3: Meeting the Needs of Vulnerable Populations 



Awardee: Department of Health and 

Mental Hygiene 

State of Maryland 

201 West Preston Street, Room 225 

Baltimore, MD 21201 
HCFA Project Lori Teichman, Ph.D. 
Officer: Division of Health Information and 

Outcomes 

Description: Maryland is one of five States receiving a 
multi-year award that was directed to increase the number 
of Medicaid-eligible pregnant substance abusers who 
received coordinated perinatal care services, substance 
abuse treatment, and other relevant direct services for 
improving the health status of both mothers and their 
infants. The demonstration projects in Massachusetts, 
New York, South Carolina, and Washington required 
waivers, while the Maryland project did not require 
waivers. The project participants in the Maryland 
program have received targeted case management under 
the provisions of the Consolidated Omnibus Budget 
Reconciliation Act of 1985, which permits targeted case 
management to Medicaid recipients. 

This initiative is designed to fill a critical gap in 
improving birth outcomes for Medicaid enrollees. Even 
when pregnant substance abusers are identified and 
services are available, there is a high risk that these 
women will not use appropriate services. This 
demonstration was designed to test whether the 
combination of case management in conjunction with 
support groups and comprehensive prenatal and drug 
treatment services is a more cost-effective outreach 
strategy than support groups alone. Outreach services for 
this project are carried out under the auspices of the Johns 
Hopkins Hospital (JHH) Comprehensive Women's Center 
(CWC), in conjunction with the JHH Prenatal Care 
Clinic. The CWC is a well-established drug treatment 
program, developed to provide specialized substance 
abuse services for women of childbearing age. The JHH is 
one of the largest providers of prenatal care to Medicaid 
women in Maryland. 

Status: As of June 30, 1996, 154 women were 
participating in the randomized clinical intervention 
(52 in the clinical services group only, 43 in the clinical 
services and support group only, and 59 in the clinical 
services and support group with the individualized case 
management component). The final period of funding for 
the demonstration was for October 1 995 through 
December 1996. The eligible study participants will 
continue to receive services through December 31, 1996. 
The project will continue with a no-cost extension from 
January 1997 through July 1997 for the data needs of the 
evaluation contractor (MPR, Inc.), and will provide a 
phase-down period for the recently serviced client groups. 



91-087 Coordinating Care for Pregnant Substance 
Abusers Demonstration: Massachusetts 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-C-06111/5 

September 1991-December 1996 

$ 1,125,000 

Cooperative Agreement 

Bruce Bullen, Commissioner 
Division of Medical Assistance 
State of Massachusetts 
Department of Public Welfare 
600 Washington Street, 5th Floor 
Boston, MA 02111 
Lori Teichman, Ph.D 
Division of Health Information and 
Outcomes 



Description: Massachusetts is one of five States receiving 
a multi-year award that was directed to increase the 
number of Medicaid-eligible pregnant substance abusers 
who received coordinated perinatal care services, 
substance abuse treatment, and other relevant direct 
services for improving the health status of both mothers 
and their infants. The MOTHERS (Medicaid 
Opportunities To Help Enter Recovery Services) project 
represented a program evaluation of the recruitment, 
enrollment, and treatment of pregnant women using illicit 
drugs in the greater Boston and Holyoke areas of the 
State. The site outcomes are to include a study of the costs 
and benefits associated with long-term treatment 
strategies, including residential, outpatient, and formal 
care following detoxification in 1 of 1 1 freestanding 
detoxification centers. Comparison between women who 
enter residential and outpatient treatment facilities will 
permit assessments of the relative impacts of these 
different modes of treatment. 

Status: The project received waiver approval for a 3-year 
period (July 1, 1993, through June 30, 1996). The final 
period of funding for the demonstration was for 
October 1995 through December 1996. The project will 
continue with a no-cost extension from January 1997 
through July 1997 for the data needs of the evaluation 
contractor (MPR, Inc.). The recruitment of women into 
the program ended December 31, 1995: a total of 
663 women were serviced in the demonstration project. 

91-086 Coordinating Care for Pregnant Substance 
Abusers Demonstration: New York 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 



ll-C-06 115/5 
September 1991-July 1997 
$ 1,700,000 
Cooperative Agreement 

Richard T. Cody 



Theme 3: Meeting the Needs of Vulnerable Populations 



101 



Awardee: New York State Department of 

Social Services 

Division of Health and Long Term Care 

40 North Pearl Street 

Albany, NY 12243-0001 
HCFA Project Bonnie M. Edington 
Officer: Division of Health Information and 

Outcomes 

Description: This demonstration seeks to increase the 
number of Medicaid-eligible pregnant substance abusers 
who receive coordinated perinatal care services, substance 
abuse treatment, and related support services, in order to 
bring about better health outcomes for these women and 
their infants. New York was one of five sites receiving 
demonstration awards in September 1991. Features 
common to all five projects include case-finding, case 
management, provider training, community outreach, and 
certain ancillary services, e.g., parenting education, 
nutrition counseling, and transportation to non-medical 
support services. 

The New York project has six sites, three in New York 
City and three in upstate New York. The project has 
waivers permitting Medicaid to cover: residential 
treatment in institutions for mental disease (IMDs); and 
support services provided by medically supervised 
outpatient programs, including child care, vocational and 
adult educational activities, life skills/self-esteem 
building, and health education. 

Status: As of September 1995, when enrollment ended, 
the project had enrolled 509 clients. Waivered prenatal 
and post-natal services for these clients were provided 
through September 1996. The remaining period of the 
demonstration will involve data collection, record 
matching, analysis of data, and report writing. 

91-085 Coordinating Care for Pregnant Substance 
Abusers Demonstration: South Carolina 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-C-06 112/5 

September 1991-December 1996 

$ 1,441,000 

Cooperative Agreement 

Gwen Power, Interim Director 

State of South Carolina 

Department of Health and 

Human Services 

P. O. Box 8206 

Columbia, SC 29202-8206 

Lori Teichman, Ph.D. 

Division of Health Information and 

Outcomes 



receiving a multi-year award that was directed to increase 
the number of Medicaid-eligible pregnant substance 
abusers who received coordinated perinatal care services, 
substance abuse treatment, and other relevant direct 
services for improving the health status of both mothers 
and their infants. The SC "Transitions" project was 
implemented in the Edisto Health District, encompassing 
Calhoun, Orangeburg, and Bamberg Counties. The site is 
a poor area both urban and rural, where 58 percent of the 
population is African American, and 60 percent of the 
women are Medicaid-eligible. The State Medicaid 
agency's High Risk Channeling Project (HRCP) Freedom 
of Choice (FOC) Waiver is the point of entry into 
"Transitions." The demonstration project is used to 
supplement services through a family-centered solution 
process for clients. The Department of Alcohol and Other 
Drug Abuse Services (DAODAS) coordinates with the 
Department of Health in providing a program centered on 
the three components of social work outreach services, 
perinatal/clinical substance abuse, services, and program 
evaluation. 

Status: The project has received waiver approval for a 
3-year period (July 1, 1993, through June 30, 1996). The 
final period of funding for the demonstration was for 
October 1995 through December 1996. The project will 
continue with a no-cost extension from January 1997 
through July 1997 for the data needs of the evaluation 
contractor (MPR, Inc.). The project continues to provide 
services to the enrolled high-risk clients in the phase- 
down period of the demonstration. 

91-096 Coordinating Care for Pregnant Substance 
Abusers Demonstration: Washington 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-C-06 108/5 
September 1991-July 1997 
$ 1,125,000 
Cooperative Agreement 

Kathy Apodaka 

Washington State Department of 

Social and Health Services 

Office of First Steps, Mail Stop OB-45A 

Olympia, WA 98504 

Bonnie M. Edington 

Division of Health Information and 

Outcomes 



Description: South Carolina (SC) is one of five States 



Description: This demonstration seeks to increase the 
number of Medicaid-eligible pregnant substance abusers 
who receive coordinated perinatal care services, substance 
abuse treatment, and related support services, in order to 
bring about better health outcomes for these women and 
their infants. Washington State was one of five sites 
receiving demonstration awards in September 1991. 
Features common to all five projects include case finding, 



102 



Theme 3: Meeting the Needs of Vulnerable Populations 



case management, provider training, community outreach, 
and certain ancillary services, e.g., parenting education, 
nutrition counseling, and transportation to non-medical 
support services. 

The Yakima First Steps Mobilization Project for 
Substance Abusing Pregnant Women: First Steps Plus is 
being conducted in Yakima County, and provides a 
continuum of care for low-income, pregnant substance 
abusers. Medicaid maternity care services provided 
through Washington's First Steps program are combined 
or coordinated with chemical addiction treatment and 
social services. Project services are provided throughout 
pregnancy and delivery, and for up to 1 year after 
delivery. The project expands the range of Medicaid 
services and increases coordination of the service-delivery 
community through communication, collaboration, and 
training. Additional Medicaid services provided through 
waivers include: 

• Expanded outreach activities, including a mobile 
substance-abuse assessment worker, and a screening 
form to assist prenatal care providers in identifying 
substance abusers. 

• Expanded case management to provide more intensive 
involvement with project participants, and an increased 
payment rate for case-management agencies. 

• Residential treatment in institutions for mental disease 
(IMDs) with specialized medical stabilization, 
detoxification, and treatment slots. 

• Child care during substance abuse treatment. 

Status: The project began enrolling eligible substance 
abusing pregnant women and providing services on 
July 1, 1993. Approximately 1,000 women and their 
children were expected to receive demonstration services 
during the 3-year operational phase. As of June 1996, 
more than 1,000 clients were enrolled, and service 
provision will continue through the last enrollee's post- 
partum period. 

95-075 Data Users' Conference for 
Historically Black Colleges and Universities 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



HCFA-95-0719 

September 1995-January 1996 

$ 25,000 

Contract 

Dean Thomas Blocker 

Morehouse College 

830 Westview Drive, SW. 

Atlanta, GA 30314 

Richard Bragg 

Division of Aging and Disability 



users' conference for Historically Black Colleges and 
Universities (HBCUs). The purpose of the data conference 
is to enhance the capacity of HBCUs to participate in the 
broad array of HCFA program activities. Specifically, 
HCFA hopes to increase the participants' capability to 
conduct health services research using HCFA data. As a 
result of participating in this conference, HCFA 
anticipates that HBCUs will become involved in the 
design, implementation, and operation of research 
projects that address health care issues such as reform, 
financing, delivery, access, and quality. This conference is 
an initial attempt to develop ties between researchers at 
these universities and HCFA staff. It is planned to foster a 
research network among the HBCUs regarding health 
care issues. 

This is the first data conference sponsored by HCFA in 
support of research efforts at HBCUs. The Data Users' 
Conference will provide opportunities for HBCUs and 
their researchers (faculty members) to work with HCFA 
staff and to develop a greater understanding of the 
research priorities and opportunities that exist. A greater 
awareness and involvement of HBCUs in HCFA programs 
would serve four important purposes: 

• To become knowledgeable about these African- 
American institutions. 

• To understand HBCUs' abilities to implement efforts to 
address the health and social problems of concern to the 
Department of Health and Human Services. 

• To increase the pool of researchers available in carrying 
out the research, demonstration, and evaluation 
activities of HCFA. 

• To fulfill the requirements of Executive Order 12876, in 
which the President has ordered Federal agencies to 
support the development and increase the utilization of 
the resources that exist at HBCUs. 

Status: The Data Users' Conference was held on 
October 18-19, 1995. The following task was completed: 
assisting and facilitating conference participants in 
developing a regional research network to address health 
care issues in the African-American community. 

93-079 Demonstration Project for Preventive and 
Primary Pediatric Care: Maryland 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



Description: The Health Care Financing Administration 
provided funds to Morehouse College to facilitate a data 



ll-W-00003/3 

October 1 993-September 1998 

Waiver-only Project 

Grant 

Joseph M. Millstone 

Department of Health and 

Mental Hygiene 

State of Maryland 

201 West Preston Street 

Baltimore, MD 21201 



Theme 3: Meeting the Needs of Vulnerable Populations 



103 



HCFA Project Sherrie L. Fried 
Officer: Office of State Health Reform 

Demonstrations 

Description: Waivers have been approved for a 5-year 
period, beginning October 1, 1993, to cover children 
under Medicaid who meet the following criteria: born 
after September 30, 1993; between 1 and 19 years of age; 
not currently eligible for the Medicaid program; and 
living in families whose income does not exceed 
185 percent of the Federal poverty level, with no resource 
limitation. Maryland intends to demonstrate that access to 
basic primary care and preventive services increases the 
utilization of such services, improves health outcomes, 
and is cost effective by preventing acute and chronic 
medical conditions. No hospital inpatient, outpatient, or 
emergency-room coverage will be provided under the 
demonstration. 

Status: Enrollment has been lower than anticipated, 
despite extensive outreach efforts. Currently, there are 
5,030 children enrolled. The State is working on various 
strategies to increase enrollment. The project has awarded 
a radio outreach contract to a local advertising agency to 
develop radio spots and ensure that these are run on 
stations throughout Maryland. The spots will continue to 
target children and pregnant women in need of health 
care services. 

94-088 Design of a Cost-Effectiveness Protocol 
for the Morbidity and Mortality in 
Hemodialysis Clinical Trials 

Project No.: 500-92-0023DO07 

Period: December 1993-October 1995 

Funding: $ 160,752 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Anthony Bower, Ph.D. 

Awardee: Rand Corporation 

(See page 194) 
HCFA Project Joel W. Greer, Ph.D. 
Officer: Division of Health Information and 

Outcomes 

Description: The hemodialysis clinical trials (HEMO) is a 
randomized controlled clinical trial sponsored by the 
National Institute for Diabetes and Digestive and Kidney 
Diseases testing the efficacy of high-flux dialyzers and of 
increasing the quantity of dialysis, as measured by double 
pool kinetic modeling. This project developed a protocol 
for conducting a cost-effectiveness analysis of the HEMO 
study. 

Status: Rand has completed and submitted the final 
report. The report contains a pilot-tested data collection 
protocol including methods, instruments and instruction 



manuals for measuring and estimating the cost of 
hemodialysis and other medical services to the study 
population in each of the treatment arms of the HEMO 
clinical trial. Data collection will involve a trained 
economist visiting each of the trial study sites to collect 
dialysis-facility cost data and patient acuity information. 
Data from Health Care Financing Administration billing 
records will provide cost data for other medical services. 

96-069 Determinants of Barriers to Minority Access to 
Health Care and Differential Health Care Utilization 
Between Older African Americans and Caucasians 

Project No.: 20-C-9072 1/3-01 

Period: September 1996-May 1998 

Funding: $ 168,932 

Award: Cooperative Agreement 

Principal 

Investigator: Thomas Obisesan, M.D. 

Awardee: Howard University Hospital 

2041 Georgia Avenue, Northwest 

Washington, DC 20060 
HCFA Project Richard Bragg 
Officer: Division of Aging and Disability 

Description: The objectives of this proposal are: 

• To examine the differences in health status and 
socioeconomic status of elderly African Americans, 
determining how these factors influence their use of 
health and long-term-care services. 

• To investigate the combined influences of informal 
support networks and formal health care programs in 
the lives of the African-American elderly, and how 
these factors influence nursing home placement and 
mortality. 

• To examine the assumption that as a minority group 
member, the African- American elderly receive more 
support from their informal networks than non-minority 
elderly. 

The focus of the study will be to examine the health 
utilization and outcomes for these two groups over a 
4-year period. 

Status: This project is in the early design phase. 

94-023 Development of Outcome-Based 
Quality Assurance Measures for Small, 
Integrated Services Settings 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 



HCFA-94-0952 

July 1994-January 1996 

$ 22,750 
Contract 

James Gardner, Ph.D. 



104 



Theme 3: Meeting the Needs of Vulnerable Populations 



Awardee: 



HCFA Project 
Officer: 



The Accreditation Council 

8100 Professional Place, Suite 204 

Landover, MD 20785 

Samuel L. Brown 

Division of Aging and Disability 



Description: The purpose of this contract is to determine 
the cost of applying outcome measures in small, 
integrated service settings. This study will provide a 
database to maintain information on quality reviews of 
organizations that serve people with disabilities, an 
analysis of individual and organizational variables that 
relate to desirable outcomes, and a final report that 
analyzes quality reviews conducted in accordance with the 
outcome-based performance measures developed by the 
Accreditation Council on Services for People with 
Disabilities. The results will be used to assess the quality 
of services in facilities serving people with chronic mental 
illness, physical challenges, and mental retardation in 
diverse settings such as supported independent living or 
intermediate care facilities for the mentally retarded. Of 
particular importance is the assessment of the extent to 
which the outcome-based performance measures can 
coexist with the traditional quality assurance variables, 
such as abuse, neglect, safety, health, and physical and 
psychological welfare. 

Status: During the period September through 
December 1994, seven organizations participated in the 
Accreditation Council's review process. During these 
reviews, staff from the Accreditation Council interviewed 
54 people served by the seven organizations. A total of 
28 organization variables (e.g., types of services provided, 
license type, disabilities of people served, prior 
accreditation status) were analyzed with regard to 
outcome scores. Analysis of outcome data was also 
performed on the characteristics of the individual people 
who were interviewed. These characteristics include age, 
sex, disability, living arrangement, communication 
method, services obtained, and source of person's 
funding. A final report is under review. 

92-018 Dialyzer Reuse: A Cohort Study 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-90045/3 

February 1992-December 1996 

$476,716 

Cooperative Agreement 

Harold I. Feldman, M.D. 

University of Pennsylvania 

School of Medicine 

Philadelphia, PA 19104-6095 

Joel W. Greer, Ph.D. 

Division of Health Information and 

Outcomes 



Mandate: Omnibus Budget Reconciliation Act 

of 1986 (Public Law 99-509) 

Description: The study is to determine the impact of 
reusing hemodialyzer membranes on the health status of 
end stage renal disease patients undergoing chronic 
hemodialysis in the United States, using the 1986-87 
incident cohort. The study is using an intent-to-treat 
model based on reuse at the 91st day following initiation 
of dialysis therapy. The analysis uses proportional hazards 
modeling with patient survival as the primary outcome. 

Status: The final report is published in Journal of 
American Medical Association (JAMA). See Feldman, H. 
I., Kinosian, M., Bilker, W. B., Simmons, C, Holmes, J. 
H., Pauly, M. V., and Escarce, J. J.: "The Effect of 
Dialyzer Reuse on Survival of Patients Treated with 
Hemodialysis." JAMA, Volume 276, Number 8, 
pp. 620-25, August 28, 1996. 

95-051 Diamond State Health Plan 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00063/3 

January 1996-January 2001 

Waiver-only Project 

Kay Holmes 

Delaware Health and Social Services 

1901 North DuPont Highway 

Newcastle, DE 19720 

Alisa Adamo 

Office of State Health Care Reform 

Demonstrations 



Description: The Diamond State Health Plan (DSHP) is a 
mandatory statewide Medicaid managed-care program. 
Through the DSHP, the State seeks to: 

• Increase access to preventive and primary care for the 
majority of Medicaid clients in Delaware. 

• Slow down the increase in medical costs related to the 
Medicaid population,. 

• Expand the population of people covered by the 
Medicaid program and provide insurance coverage for 
an additional 8,000 to 9,000 uninsured Delawareans. 

This new expanded population will be eligible for 
Medicaid if they have an income at or below the Federal 
poverty level (FPL). 

All Medicaid recipients are eligible for the program, with 
the exception of those receiving long-term care in 
institutional or home and community-based settings and 
those who are eligible for Medicare. Medicaid eligibles 
not eligible for DSHP will remain in the State's fee-for- 
service Medicaid. Adults and children with incomes of up 
to 100 percent of the FPL will also be eligible for health 
coverage through the DSHP. 



Theme 3: Meeting the Needs of Vulnerable Populations 



105 



Delaware has contracted with a health benefits manager 
(HBM) to facilitate and monitor member enrollment in 
managed-care plans. The HBM is responsible for outreach 
and education of potential eligibles through marketing 
and promotional activities. Delaware has contracted with 
four managed-care organizations, and everyone eligible 
for the program has a choice of at least two plans. 

Status: The program was implemented on January 1, 
1996. and the total enrollment as of September 1, 1996 
was 58,900 (or approximately 77.4 percent of the total 
Medicaid population). 

93-061 Economic and Cost-Effectiveness Studies for 
the U. S. Renal Data Svstem 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandate: 



HCFA-IA-9305 
July 1993-June 1998 
S 1,657,075 
Interagency Agreement 

Philip J. Held, Ph.D. 

National Institute of Diabetes and 

Digestive and Kidney Diseases 

Larry Agadoa, M.D. 

Building 31 

3 1 Center Drive, MSC2560 

Bethesda, MD 20892-2560 

Joel W. Greer, Ph.D. 

Division of Health Information and 

Outcomes 

Omnibus Budget Reconciliation Act 
of 1986 (Public Law 99-509) 



Description: This interagency agreement (IAA) provides 
funds to the National Institute of Diabetes and Digestive 
and Kidney Diseases (NIDDK) to cover the cost of having 
the coordinating center for the U. S. Renal Data System 
(USRDS) perform economic and cost-effectiveness 
studies. NIDDK awarded a contract to the University of 
Michigan to be the coordinating center for 5 years from 
July 1993 to July 1998. The IAA calls for the 
coordinating center to conduct cost or cost-effectiveness 
components for at least four existing data studies and for 
one special study focused on economic issues each year. 

Status: The coordinating center creates annual cost data 
sets. Two major ongoing studies are the: , 

• Costs of providing dialysis based on dialysis facility 
annual cost report data. 

• Cost-effectiveness study of vascular access techniques 
for hemodialysis. 

Sections on cost and cost effectiveness were published in 
the 1995 and 1996 USRDS Annual Data Reports. These 



reports are available from the National Technical 
Information Service. The accession number for the 1995 
report is PB95-271391; the accession number for the 1996 
report is PB97-1 11041. 

92-025 Effects of Expanded Medicaid 
Coverage of Pregnant Women 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigators: 

Awardee: 



HCFA Project 
Officer: 



18-C-90029/4 

February 1 992-February 1995 

$650,161 

Cooperative Agreement 

Wayne A. Ray, Ph.D. 

Joyce M. Piper, Dr.P.H. (deceased) 

Vanderbilt University 

School of Medicine 

21st and Garland 

Nashville, TN 37232 

Herbert A. Silverman, Ph.D. 

Division of Payment Systems 



Description: This study examined the effect of four 
Medicaid expansions in Tennessee: expanded eligibility 
for pregnant women and infants up to 100 percent of 
poverty (enacted July 1, 1987); presumptive eligibility 
(enacted February 1, 1989); enhanced prenatal care 
services (enacted July 1, 1989); and expanded eligibility 
for pregnant women and infants up to 1 50 percent of 
poverty (enacted January 1, 1990). Prenatal care use, 
birthweight, and infant mortality were the outcomes of 
interest. Data from Medicaid records, vital statistics, and 
the Risk Factor Surveillance Program were used to 
conduct both strata analysis and multivariate analysis to 
investigate the effect of each of the expansions separately 
and over one entire period of implementation. 

Status: This project has been completed. The findings of 
this study have been reported in the following papers: 

• Piper, J. M., Mitchel, E. F., Jr., and Ray, W. A.: 
"Expanded Medicaid Coverage for Pregnant Women to 
100 Percent of the Federal Poverty Level." American 
Journal of Preventive Medicine, Volume 10, 
Number 2, 1994. 

• Piper, J. M., Mitchel, E. F., Jr., and Ray, W. A.: 
"Presumptive Eligibility for Pregnant Medicaid 
Enrollees: Its Effects on Prenatal Care and Perinatal 
Outcome." American Journal of Public Health, 
Volume 84, Number 10, October 1994. 

• Piper, J. M., Mitchel, E. F., Jr., and Ray, W. A.: 
"Evaluation of a Program for Prenatal Care Case 
Management." Unpublished. 

• Ray, W. A., Mitchel, E. F., Jr., and Piper, J. M.: 
"Effect of Medicaid Expansions on Preterm Births." 
Unpublished. 



106 



Theme 3: Meeting the Needs of Vulnerable Populations 



The sum and substance of the findings are that the 
Medicaid expansions in Tennessee resulted in more poor 
women receiving prenatal care and receiving such care 
earlier in their pregnancy. This has resulted in a decrease 
in the proportion of women receiving inadequate prenatal 
care as measured by a modified Kessner Index. Despite 
these improvements in prenatal care, there has not been a 
discernible improvement in the incidence of low-birth- 
weight outcomes. 

96-070 Effects of Health Education on the 
Participation of African-American Men in 
Routine Screening for Prostate Cancer in 
Rural Southwest Mississippi 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigators: 

Awardee: 



HCFA Project 

Officer: 



20-C-907 18/4-01 

September 1996-September 1998 

S 291.011 

Cooperative Agreement 

Frances Henderson, Ph.D. and 

Leroy Davis, Ph.D. 

Alcorn State University 

1000 ASU Drive #210 

Lorman, MS 39096 

Richard Bragg 

Division of Aging and Disability 



Description: The purpose of this study is to increase the 
level of understanding of African-American males and 
their families about prostate cancer and prostate health. 
The level of understanding is operationally defined as 
changes in the relationships among knowledge, attitudes 
and behaviors. It is expected that at the end of this study, 
participants will demonstrate an increased level of 
understanding of prostate cancer and prostate health and 
the importance of routine screening as a result of health 
education. The objectives are: 

• To increase the knowledge level of African-American 
men about prostate health and prostate cancer as 
measured by pre and post tests. 

• To change the attitude of the African- American men 
toward prostate cancer and prostate health, as measured 
by pre and post survey data. 

• To change the behavior of African- American men in 
relation to routine screening for prostate cancer by 
increasing the number who participate in regular and 
systematic screening over a 2-year period. 

Status: This project is in the early design phase. 

91-097 Elderly Wealth and Savings: Implications for 

Long-Term Care (Formerly, Long-Term-Care Studies 
(Section 207)) 



Funding: 

Award: 

Principal 

Investigator: 

Awardee: 

HCFA Project 

Officer: 



$ 126,000 
Contract 

David Kennell 

Lewin/VHI, Inc. 

(See page 17) 

Carolyn Rimes 

Division of Aging and Disability 



Description: This study synthesizes what is known about 
the wealth of the elderly and includes recent empirical 
research conducted using the 1984 and 1989 Panel Study 
of Income Dynamics and the 1983, 1986, and 1989 
Survey of Consumer Finances. The information in this 
study is pertinent to the issue of long-term care (LTC) for 
the elderly because much of the debate concerning 
expansion of the Federal role in LTC financing centers on 
the economic status of the elderly. A key issue in the 
debate is whether or not the elderly have the financial 
resources to pay for their own LTC cost directly or 
through the purchase of private LTC insurance. 

Status: The main finding of the synthesis report is that the 
elderly, as a group, are doing well economically. Incomes 
of the elderly are lower than incomes of the non-elderly, 
but this gap narrows when taxes and other benefits (i.e., 
Medicare) are considered. Furthermore, the elderly have 
among the highest wealth holdings of any age group. 
However, the elderly face substantial economic risks, such 
as incurring unfunded catastrophic medical expenses, and 
leaving poverty is harder for the elderly than for the non- 
elderly. This study also finds that existing theories on 
both whether and why the elderly save sharply disagree 
with one another. Testing these theories is challenging 
because data sources are usually poor or out of date, and 
many of the theories do not yield refutable hypotheses. 

92-021 End Stage Renal Disease Research Studies 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandate: 



Project No.: 
Period: 



500-89-0047/17 
June 1991— August 



17-C-90085/3 
February 1992-June 1995 
$ 450,000 
Cooperative Agreement 

Philip J. Held, Ph.D. 

University of Michigan 

Kidney Epidemiology and 

Cost Center 

315 West Huron, Suite 420 

Ann Arbor, MI 48103 

Joel W. Greer, Ph.D. 

Division of Health Information and 

Outcomes 

Omnibus Budget Reconciliation Act 
of 1986 (Public Law 99-509) 



.995 



Theme 3: Meeting the Needs of Vulnerable Populations 



107 



Description: No-cost extensions until September 24, 1996 
were received and the project is completed. The purpose 
of this project is to perform cost studies of major issues for 
the end stage renal disease program. Ongoing studies 
include an analysis of the dialysis facility cost reports, 
standardized hospitalization rates, and cost effectiveness 
of different-treatment modalities. 

Status: Some papers funded in whole or in part have been 
published in professional journals: 

"Association of Dialyzer Reuse Practices and Patient 

Outcomes." American Journal of Kidney Diseases 

(AMD) 

"Effect of Race on Access to Recombinant Human 

Erythropoietin in Long-Term Hemodialysis Patients." 

Journal of the American Medical Association (JAMA) 

"The Impact of HLA Mismatches on the Survival of 

First Cadaveric Kidney Transplants." New England 

Journal of Medicine 

"Hemodialysis in the United States: What Is the Dose 

and Does It Matter?" AJKD 

"On Replacing Peer Review with Legal Challenge in 

Scientific Research: An Opinion" Seminars in Dialysis 

"Recommendations for Reducing the High Morbidity 

and Mortality of United States Maintenance Dialysis 

Patients." AJKD 

"Using USRDS Generated Hospitalization Rates to 

Compare Local Dialysis Patient Hospitalization Rates to 

National Rates." Kidney International 

"Hemodialysis Vascular Access Morbidity in the United 

States." Kidney International 

"Predictors of Type of Vascular Access in Hemodialysis 

Patients." JAMA. 

91-089 Essential Access Community Hospital/Rural 
Primary Care Hospital Program: California 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



60-P-07011/9 

September 1991— September 

$ 1,798,602 

Grant 



997 



HCFA Project 
Officer: 



Mandate: 



Ernesto Iglesias 

Office of Statewide Health Planning 

and Development 

Primary Care Resources and 

Community Development Division 

1 600 9th Street, Room 440 

Sacramento, CA 95814 

Sheldon Weisgrau 

Division of Delivery Systems and 

Financing 

Section 1 820 of the Social Security Act 
(Public Law 101-239) 



Description: The Essential Access Community Hospital/ 
Rural Primary Care Hospital (EACH/RPCH) program is 
designed to assist States in maintaining access to health 
care services in rural areas through the development of 
rural health plans, establishment of rural health networks, 
and creation of a limited-service alternative for 
communities that can no longer support a full-service 
hospital. The EACH/RPCH program consists of: 

• A permanent operating program that establishes the 
EACH as a new hospital category and the RPCH as a 
new type of health care facility that provides 
emergency, outpatient, and limited inpatient services. 

• Grants to States and hospitals to assist in the 
development and implementation of the program. 

EACHs, RPCHs, and other health care providers are 
organized into rural health networks that maintain 
agreements for such services as the transfer and referral of 
patients, the provision of transportation services, and the 
development and use of communications systems. The 
statute limits the program to seven States. Through a 
competitive process, the Health Care Financing 
Administration (HCFA) selected California, Colorado, 
Kansas, New York, North Carolina, South Dakota, and 
West Virginia to participate. Through fiscal year 1996, 
HCFA has awarded a total of $23.7 million in grant funds 
to these States and 96 hospitals in these States for 
program planning and participation. 

Status: The State of California is one of seven States 
participating in the EACH/RPCH program. Since 1991, 
the California Office of Statewide Health Planning and 
Development has received $714,102 in grant funding for 
program planning, development, and implementation. 
Grants totaling $1,084,500 have also been awarded to 
seven California hospitals in three rural health networks. 

91-090 Essential Access Community Hospital/Rural 
Primary Care Hospital Program: Colorado 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



60-P-07006/8 
September 1991 
$ 4,523,039 
Grant 



-September 1997 



HCFA Project 
Officer: 



Louise Singleton 

Colorado Department of Public 

Health and Environment 

Rural and Primary Health Policy 

Health and Planning 

4300 Cherry Creek Drive, South 

Denver, CO 80222-1530 

Sheldon Weisgrau 

Division of Delivery Systems and 

Financing 



108 



Theme 3: Meeting the Needs of Vulnerable Populations 



Mandate: Section 1820 of the Social Security Act 

(Public Law 101-239) 

Description: The Essential Access Community Hospital/ 
Rural Primary Care Hospital (EACH/RPCH) program is 
designed to assist States in maintaining access to health 
care services in rural areas through the development of 
rural health plans, establishment of rural health networks, 
and creation of a limited-service alternative for 
communities that can no longer support a full-service 
hospital. The EACH/RPCH program consists of: 

• A permanent operating program that establishes the 
EACH as a new hospital category and the RPCH as a 
new type of health care facility that provides 
emergency, outpatient, and limited inpatient services. 

• Grants to States and hospitals to assist in the 
development and implementation of the program. 

EACHs, RPCHs, and other health care providers are 
organized into rural health networks that maintain 
agreements for such services as the transfer and referral of 
patients, the provision of transportation services, and the 
development and use of communications systems. The 
statute limits the program to seven States. Through a 
competitive process, the Health Care Financing 
Administration (HCFA) selected California, Colorado, 
Kansas, New York, North Carolina, South Dakota, and 
West Virginia to participate. Through fiscal year 1996, 
HCFA has awarded a total of $23.7 million in grant funds 
to these States and 96 hospitals in these States for 
program planning and participation. 

Status: The State of Colorado is one of seven States 
participating in the EACH/RPCH program. Since 1991, 
the Colorado Office of Rural and Primary Health Policy 
and Planning has received $1,459,904 in grant funding 
for program planning, development, and implementation. 
Grants totaling $3,074,135 have also been awarded to 
16 Colorado hospitals in 9 rural health networks. As of 
September 1996, two RPCHs in two rural health networks 
in Colorado have been certified to participate in the 
Medicare program. 

91-091 Essential Access Community Hospital/Rural 
Primary Care Hospital Program: Kansas 



HCFA Project 
Officer: 



Mandate: 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



60-P-07017/7 

September 1991-September 1997 

$ 5,799,223 
Grant 

Thomas R. Sipe 

Kansas Department of Health 

and Environment 

Bureau of Local and Rural 

Health Systems 

900 SW. Jackson 

Topeka, KS 66612-1290 



Sheldon Weisgrau 

Division of Delivery Systems 

and Financing 

Section 1820 of the Social Security Act 
(Public Law 101-239) 



Description: The Essential Access Community Hospital/ 
Rural Primary Care Hospital (EACH/RPCH) program is 
designed to assist States in maintaining access to health 
care services in rural areas through the development of 
rural health plans, establishment of rural health networks, 
and creation of a limited-service alternative for 
communities that can no longer support a full-service 
hospital. The EACH/RPCH program consists of: 

• A permanent operating program that establishes the 
EACH as a new hospital category and the RPCH as a 
new type of health care facility that provides 
emergency, outpatient, and limited inpatient services. 

• Grants to States and hospitals to assist in the 
development and implementation of the program. 

EACHs, RPCHs, and other health care providers are 
organized into rural health networks that maintain 
agreements for such services as the transfer and referral of 
patients, the provision of transportation services, and the 
development and use of communications systems. The 
statute limits the program to seven States. Through a 
competitive process, the Health Care Financing 
Administration (HCFA) selected California, Colorado, 
Kansas, New York, North Carolina, South Dakota, and 
West Virginia to participate. Through fiscal year 1996, 
HCFA has awarded a total of $23.7 million in grant funds 
to these States and 96 hospitals in these States for 
program planning and participation. 

Status: The State of Kansas is one of seven States 
participating in the EACH/RPCH program. Since 1991, 
the Kansas Bureau of Local and Rural Health Systems has 
received $979,702 in grant funding for program planning, 
development, and implementation. Grants totaling 
$4,819,521 have also been awarded to 29 Kansas 
hospitals in 9 rural health networks. As of September 
1996, 1 1 RPCHs in Kansas have been certified to 
participate in the Medicare program. 

91-092 Essential Access Community Hospital/Rural 
Primary Care Hospital Program: New York 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 



60-P-07015/2 

September 1991-September 1997 

$ 2,272,432 
Grant 

Walt Gregg 



Theme 3: Meeting the Needs of Vulnerable Populations 



109 



Awardee: 



HCFA Project 
Officer: 



Mandate: 



New York State Department of Health 

Office of Rural Health 

Corning Tower, Room 1656 

Empire State Plaza 

Albany, NY 12237 

Sheldon Weisgrau 

Division of Delivery Systems and 

Financing 

Section 1820 of the Social Security Act 
(Public Law 101-239) 



Description: The Essential Access Community Hospital/ 
Rural Primary Care Hospital (EACH/RPCH) program is 
designed to assist States in maintaining access to health 
care services in rural areas through the development of 
rural health plans, establishment of rural health networks, 
and creation of a limited-service alternative for 
communities that can no longer support a full-service 
hospital. The EACH/RPCH program consists of: 

• A permanent operating program that establishes the 
EACH as a new hospital category and the RPCH as a 
new type of health care facility that provides 
emergency, outpatient, and limited inpatient services. 

• Grants to States and hospitals to assist in the 
development and implementation of the program. 

EACHs, RPCHs, and other health care providers are 
organized into rural health networks that maintain 
agreements for such services as the transfer and referral of 
patients, the provision of transportation services, and the 
development and use of communications systems. The 
statute limits the program to seven States. Through a 
competitive process, the Health Care Financing 
Administration (HCFA) selected California, Colorado, 
Kansas, New York, North Carolina, South Dakota, and 
West Virginia to participate. Through fiscal year 1996, 
HCFA has awarded a total of $23.7 million in grant funds 
to these States and 96 hospitals in these States for 
program planning and participation. 

Status: The State of New York is one of seven States 
participating in the EACH/RPCH program. Since 1991, 
the New York State Office of Rural Health has received 
51,225,432 in grant funding for program planning, 
development, and implementation. Grants totaling 
SI, 047, 002 have also been awarded to six New York 
hospitals in three rural health networks. As of 
September 1996, two RPCHs had been certified to 
participate in the Medicare program in New York. 

91-093 Essential Access Community Hospital/Rural 
Primary Care Hospital Program: North Carolina 

Project No.: 60-P-07012/4 

Period: September 1991 -September 1997 



Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



$4,135,369 
Grant 

Nan Rideout 

North Carolina Department of 

Human Resources 

Office of Rural Health and 

Resource Development 

3 1 1 Ashe Avenue 

Raleigh, NC 27606 

Sheldon Weisgrau 

Division of Delivery Systems 

and Financing 

Section 1820 of the Social Security Act 

(Public Law 101-239) 



Description: The Essential Access Community Hospital/ 
Rural Primary Care Hospital (EACH/RPCH) program is 
designed to assist States in maintaining access to health 
care services in rural areas through the development of 
rural health plans, establishment of rural health networks, 
and creation of a limited-service alternative for 
communities that can no longer support a full-service 
hospital. The EACH/RPCH program consists of: 

• A permanent operating program that establishes the 
EACH as a new hospital category and the RPCH as a 
new type of health care facility that provides 
emergency, outpatient, and limited inpatient services. 

• Grants to States and hospitals to assist in the 
development and implementation of the program. 

EACHs, RPCHs, and other health care providers are 
organized into rural health networks that maintain 
agreements for such services as the transfer and referral of 
patients, the provision of transportation services, and the 
development and use of communications systems. The 
statute limits the program to seven States. Through a 
competitive process, the Health Care Financing 
Administration (HCFA) selected California, Colorado, 
Kansas, New York, North Carolina, South Dakota, and 
West Virginia to participate. Through fiscal year 1996, 
HCFA has awarded a total of $23.7 million in grant funds 
to these States and 96 hospitals in these States for 
program planning and participation. 

Status: The State of North Carolina is one of seven States 
participating in the EACH/RPCH program. Since 1991, 
the North Carolina Office of Rural Health and Resource 
Development has received $1,379,369 in grant funding 
for program planning, development, and implementation. 
Grants totaling $2,756,000 have also been awarded to 
14 North Carolina hospitals in 7 rural health networks. 
As of September 1996, three RPCHs have been certified to 
participate in the Medicare program in North Carolina. 



Theme 3: Meeting the Needs of Vulnerable Populations 



91-094 Essential Access Community Hospital/Rural 
Primary Care Hospital Program: South Dakota 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandate: 



60-P-07023/8 
September 1991 
S 2,414,475 
Grant 



-September 1997 



Doug Knutson 

South Dakota Department of Health 

Office of Rural Health 

445 East Capitol Avenue 

Pierre, SD 57501-3185 

Sheldon Weisgrau 

Division of Delivery Systems and 

Financing 

Section 1820 of the Social Security Act 
(Public Law 101-239) 



Description: The Essential Access Community Hospital/ 
Rural Primary Care Hospital (EACH RPCH) program is 
designed to assist States in maintaining access to health 
care services in rural areas through the development of 
rural health plans, establishment of rural health networks, 
and creation of a limited-service alternative for 
communities that can no longer support a full-service 
hospital. The EACH RPCH program consists of: 

• A permanent operating program that establishes the 
EACH as a new hospital category and the RPCH as a 
new type of health care facility that provides 
emergency, outpatient, and limited inpatient services. 

• Grants to States and hospitals to assist in the 
development and implementation of the program. 

EACHs, RPCHs, and other health care providers are 
organized into rural health networks that maintain 
agreements for such services as the transfer and referral of 
patients, the provision of transportation services, and the 
development and use of communications systems. The 
statute limits the program to seven States. Through a 
competitive process, the Health Care Financing 
Administration (HCFA) selected California. Colorado. 
Kansas, New York, North Carolina, South Dakota, and 
West Virginia to participate. Through fiscal year 1996, 
HCFA has awarded a total of S23.7 million in grant funds 
to these States and 96 hospitals in these States for 
program planning and participation. 

Status: The State of South Dakota is one of seven States 
participating in the EACH RPCH program. Since 1991, 
the South Dakota Office of Rural Health has received 
$741,782 in grant funding for program planning, 
development, and implementation. Grants totaling 
51,672,693 have also been awarded to 12 South Dakota 
hospitals in 6 rural health networks. As of September 
1996, six RPCHs have been certified to participate in the 



Medicare program in South Dakota (one of these RPCHs 
has closed). 

91-095 Essential Access Community Hospital/Rural 
Primary Care Hospital Program: West Virginia 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandate: 



60-P-07008/3 

September 1991-September 1997 

$2,735,096 

Grant 

Sandra Pope 

West Virginia Department of Health 

and Human Resources 

Bureau for Public Health 

Office of Rural Health Policy 

1411 Virginia Street, East 

Charleston, WV 25301 

Sheldon Weisgrau 

Division of Delivery Systems and 

Financing 

Section 1820 of the Social Security Act 
(Public Law 101-239) 



Description: The Essential Access Community Hospital/ 
Rural Primary Care Hospital (EACH/RPCH) program is 
designed to assist States in maintaining access to health 
care services in rural areas through the development of 
rural health plans, establishment of rural health networks, 
and creation of a limited-service alternative for 
communities that can no longer support a full-service 
hospital. The EACH/RPCH program consists of: 

• A permanent operating program that establishes the 
EACH as a new hospital category and the RPCH as a 
new type of health care facility that provides 
emergency, outpatient, and limited inpatient services. 

• Grants to States and hospitals to assist in the 
development and implementation of the program. 

EACHs, RPCHs, and other health care providers are 
organized into rural health networks that maintain 
agreements for such services as the transfer and referral of 
patients, the provision of transportation services, and the 
development and use of communications systems. The 
statute limits the program to seven States. Through a 
competitive process, the Health Care Financing 
Administration (HCFA) selected California, Colorado, 
Kansas, New York, North Carolina, South Dakota, and 
West Virginia to participate. Through fiscal year 1996, 
HCFA has awarded a total of S23.7 million in grant funds 
to these States and 96 hospitals in these States for 
program planning and participation. 

Status: The State of West Virginia is one of seven States 
participating in the EACH/RPCH program. Since 1991, 
the West Virginia Office of Community and Rural Health 



Theme 3: Meeting the Needs of Vulnerable Populations 



111 



Services has received SI. 058. 330 in grant funding for 
program planning, development, and implementation. 
Grants totaling SI. 676, 766 have also been awarded to 
12 West Virginia hospitals in 6 rural health networks. 
As of September 1996, six RPCHs have been certified to 
participate in the Medicare program in West Virginia. 

95-073 Evaluation and Technical Assistance of the 
Medicare Alzheimer's Disease Demonstration 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



500-95-0015 
May 1995-April 
$ 802,642 
Contract 



.997 



HCFA Project 
Officer: 

Mandates: 



Robert J. Newcomer, Ph.D. 

Institute for Health and Aging 

University of California at 

San Francisco 

201 Filbert Street 

Box 0646, Laurel Heights 

San Francisco, CA 94133-0646 

Dennis M. Nugent 

Division of Aging and Disability 

Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 

Omnibus Budget Reconciliation Act of 

1990 (Public Law 101-508) 

Omnibus Budget Reconciliation Act of 

1993 (Public Law 103-66) 



Description: The purpose of the Medicare Alzheimer's 
Disease Demonstration was to determine the effectiveness, 
cost, and impact on health status and functioning of 
providing comprehensive in-home and community-based 
services to beneficiaries who have dementia. Two models 
of care were studied under this project. Both models 
included case management and a wide range of services, 
such as homemaker/personal care services, adult day care, 
companion services, caregiver education, and family 
counseling. The two models varied by the intensity of the 
case management provided to beneficiaries and their 
caregivers and the amount of demonstration service costs 
that could be paid for by Medicare each month. Some 
questions to be addressed by the evaluation are: 

• What factors are associated with the cost-effectiveness 
of providing an expanded package of home care and 
community-based services to Medicare beneficiaries 
with Alzheimer's disease or related disorders? 

• How do various services affect the health status and 
functioning of dementia patients and their caregivers? 

• What are the effects of providing community-based 
services on caregiver burden and stress? 

• Do additional home care services delay or prevent 
institutionalization of beneficiaries with dementia? 



Status: The Medicare Alzheimer's Disease Demonstration 
was extended twice by congressional legislation. Because 
of the protractive length of the project, the original 
Evaluation and Technical Assistance contract with the 
University of California at San Francisco expired prior to 
the completion of the evaluation. A new contract was 
awarded to enable the University of California at San 
Francisco to complete its analysis and interpretation of 
the demonstration's primary and secondary data. 

93-074 Evaluation of Clinical and Educational 
Services to Rural Hospitals via Fiber-Optic Cable 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-90254/7 
September 1993- 
$ 698,322 
Grant 



September 1996 



Ginny Wagner 

Iowa Health System 

1200 Pleasant Street 

Des Moines, IA 50309 

Lawrence E. Kucken 

Division of Health Information and 

Outcomes 



Description: This project is providing the Health Care 
Financing Administration with an evaluation of the 
effectiveness of a telemedicine system linking hospitals to 
an existing statewide fiber-optic communications 
network. The Iowa Methodist Medical Center has been 
linked to both Greene County Medical Center and Trinity 
Regional Hospital. Project services include telemedicine 
(e.g., radiology, cardiology, pathology consultations), 
education, and information systems components. Because 
of the limited sample size, the evaluation is focused on 
input and process indicators, as opposed to outcome 
indicators. 

Status: The final report has been received and is under 
review. 

93-073 Evaluation of Medicaid Managed-Care 
Programs with 1915(b) Waivers 

Project No.: 500-92-0033DO02 

Period: September 1 993— December 1996 

Funding: $ 752,256 

Award: Delivery Order in Master Contract 

Principal 

Investigator: James Lubalin, Ph.D. 

Awardee: Research Triangle Institute 

(See page 132) , 

HCFA Project James P. Hadley 
Officer: Office of State Health Reform 

Demonstrations 



112 



Theme 3: Meeting the Needs of Vulnerable Populations 



Description: The purpose of this contract is to design and 
conduct an evaluation of the Medicaid managed-care 
initiatives implemented through 1915(b) waivers. The 
evaluation will provide information to the Health Care 
Financing Administration and the States on the extent to 
which various features of the managed-care projects 
contribute to the ability of the Medicaid program to 
deliver cost-effective care to Medicaid-eligible 
populations. The evaluation will use interview data, 
studies submitted by the States as part of their waiver 
applications, and individual-level use and cost data to 
examine the cost effectiveness of the projects, as well as 
the quality of care and satisfaction experienced by 
enrollees in the managed-care programs relative to a fee- 
for-service alternative. 

Status: The evaluation is examining 1915(b) programs in 
California, Florida, New Mexico, Ohio, Washington, New 
York, and Wisconsin. Case studies of these States have 
been completed. Analyses of use and cost data from 
California, Florida, New Mexico, and Ohio is under way. 
A final report synthesizing case study and secondary data 
analyses is due to be completed December 31,1 996. 

95-058 Evaluation of Rural Health Clinics 

Project No.: 500-92-0047DO03 

Period: September 1995-March 1997 

Funding: S 316,051 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Valerie Cheh, Ph.D. 

Awardee: Mathematica Policy Research, Inc. 

(See page 138) 
HCFA Project Siddhartha Mazumdar, Ph.D. 
Officer: Division of Delivery Systems and 

Financing 

Description: The Rural Health Clinic Services Act of 
1977 (Public Law 95-210) authorized a new type of 
provider for certification and licensure. A rural health 
clinic (RHC) must be located in a rural health 
professional shortage area, medically underserved area, or 
Governor-designated shortage area, and it must make use 
of mid-level practitioners. The legislation provides for 
cost-based reimbursement for the clinics for Medicare and 
Medicaid. After a slow start in certifying clinics in the 
first years of the program, there has been rapid growth in 
the numbers of these clinics in the past few years. 
According to a count by the Health Care Financing 
Administration, there were 3,067 RHCs listed nationwide 
in September 1996, compared to 1,157 certified clinics in 
August 1993. 

The purpose of this contract is an evaluation of this 
program, which will focus on several broad issue areas 
that have implications for rural health policy at the 



Federal and State levels. These overall issue areas are: 

• What are the reasons for the growth in the numbers of 
the RHCs? 

• What has been the impact on access to health care for 
rural populations as a result of the growth in these 
clinics, especially the Medicare, Medicaid, and 
otherwise underserved populations? 

• What have been the costs to the Federal Government 
and the States for the program? 

Other broad questions pertinent to the entire spectrum of 
rural health policy will also be addressed, such as whether 
these clinics are increasing the supply of physicians in 
rural areas, what implications the growth in clinics has 
for Federal policy for rural hospitals and other providers, 
and whether these clinics should be protected in the 
development of State managed-care plans. 

Status: The research team is in the process of conducting 
site visits and data analysis. 

89-033 Evaluation of the Arizona Health Care 
Cost Containment System 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-89-0067 

September 1 989-February 1996 

$ 3,856,934 

Contract 

Nelda McCall 

Laguna Research Associates 

455 Market Street, Suite 1190 

San Francisco, CA 94105 

Joan Peterson, Ph.D. 

Office of State Health Reform 

Demonstrations 



Description: The awardee evaluated the continuing 
operation of the Arizona Health Care Cost Containment 
System (AHCCCS), including the Arizona Long-Term 
Care System (ALTCS). AHCCCS operates a statewide 
Medicaid managed-care program for Aid to Families with 
Dependent Children and Supplemental Security Income 
eligibles. Major research questions investigated include: 

• What is the overall utilization of medical services under 
the program? How does it compare to other programs? 

• Is there evidence of quality issues in the ALTCS or of 
selection bias in the acute-care program? 

• What does the AHCCCS program cost and how does 
that compare to what a traditional Medicaid program 
would have cost in Arizona? 

Status: This evaluation was completed in February 1996. 
Four implementation and operation reports and four 
outcome reports were produced. The final report was 
submitted in February 1996. According to these reports, 
ALTCS' use of home community-based services appears 



Theme 3: Meeting the Needs of Vulnerable Populations 



113 



to be cost effective for both the elderly and physically 
disabled and the mentally retarded/developmentally 
disabled populations. The Prepaid Medicaid Management 
Information System (PMMIS) development effort has 
been completed. PMMIS development and operational 
costs were considerably greater than originally 
anticipated, and many of the expected financial benefits 
have not been realized. However, many significant 
intangible benefits have been experienced, including the 
ready access to critical program information. The results 
of the quality-of-care analysis indicate that ALTCS 
nursing home residents are more likely to experience a 
decubitus ulcer, a fever, or a catheter insertion than 
nursing home residents covered by New Mexico 
Medicaid. The cost of the AHCCCS program during its 
first 1 1 fiscal years (FY) 1983-93 averaged 1 1.2 percent 
less than the cost of a traditional program in Arizona for 
medical costs only. When administrative costs are 
factored in, AHCCCS still cost 6.9 percent less, on 
average, during the same period when compared to a 
traditional Medicaid program. The ALTCS program also 
cost less than a traditional Medicaid program. Total costs 
(medical and administrative) of ALTCS were estimated to 
be 7 percent less in FY 89, 8 percent less in FY 90, 
15 percent less in FY 91, 22 percent less in FY 92, and 
21 percent less in FY 93. 

90-006 Evaluation of the Cost Effectiveness of 
Medicare Coverage of Influenza Vaccine 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandate: 



500-89-0049 

October 1 989-December 1994 

$ 3,062,471 

Contract 

David Kidder, Ph.D. 
Abt Associates, Inc. 
55 Wheeler Street 
Cambridge, MA 02138 
Edward T. Hutton, Ph.D. 
Office of State Health Reform 
Demonstrations 

Omnibus Budget Reconciliation Act of 
1987 (Public Law 100-203) 



Description: The objective of this project was to evaluate 
the cost effectiveness of furnishing influenza vaccinations 
to Medicare Part B beneficiaries as a Medicare-covered 
benefit. The demonstration included intervention and 
comparison areas in 10 sites and 10 statewide vaccine 
projects. In the former paired sites, bulk-purchased 
vaccine was distributed to providers, intensive beneficiary 
and provider motivation campaigns were undertaken, 
private providers were paid $8 per dose to administer the 
vaccine (clinics were paid $4), and a dedicated carrier 
processed the claims. In the statewide sites, an influenza 



vaccination was treated as a covered benefit, and the local 
carrier paid providers for the cost of the vaccine and its 
administration. For the evaluation, the contractor is 
measuring the cost of the immunization benefit relative to 
the reduction in pneumonia and influenza hospitalization 
admissions (attributable to vaccine use) during the 
influenza season. The vaccine's effectiveness in 
preventing pneumonia and influenza hospital admissions 
was estimated through case control studies included in the 
demonstration. A national panel of experts assisted the 
Health Care Financing Administration, the Centers for 
Disease Control and Prevention, and the contractor in 
conducting the demonstration and evaluation. 

Status: Effective May 1, 1993, Medicare began paying for 
influenza vaccinations. As permitted by Congress through 
Section 4071 of Public Law 100-203, this service adds to 
the package of prevention services that Medicare already 
covers, which includes hepatitis B vaccines, 
pneumococcal pneumonia vaccines, mammograms, and 
Pap smears. Measures of vaccine effectiveness during the 
defined influenza circulation period of severe influenza 
season were estimated to range from 32 to 45 percent. 
This range, which includes estimates from two severe 
seasons and four studies, may be viewed as low because of 
possible misclassification of cases since a confirmatory 
lab test for a preceding influenza illness was not possible. 
Overall survey vaccination rates for the fourth year of the 
demonstration (1991-92) were determined to be 59 and 
46 percent, respectively, in the intervention and 
comparison areas. Influenza vaccination levels in 4 of 
10 intervention sites exceeded the national health 
objective for the year 2000 of 60-percent vaccine coverage 
among non-institutionalized persons 65 years of age and 
over, and overall vaccination levels in the demonstration 
(59 percent) nearly reached this objective. Taking into 
account the 2-point differential in vaccination rates in 
intervention and comparison areas that was observed at 
baseline, the demonstration is inferred to have increased 
vaccine coverage by 1 1 points. Vaccine coverage was 
increased through a variety of activities to promote and 
distribute vaccines to Medicare beneficiaries. These 
activities included Medicare paying for the administration 
and bulk purchase of the vaccine, sending informational 
letters to beneficiaries living in the demonstration areas, 
and using motivational techniques to make influenza 
vaccination a routine practice in provider offices. The 
contractor completed a national and demonstration 
follow-up survey of vaccine coverage during the 1993-94 
influenza season among Medicare beneficiaries, which 
found that the national rate of influenza vaccine coverage 
was 58 percent of Medicare eligibles and 28 percent for 
pneumococcal vaccine. Published reports from the i 
Medicare Influenza Vaccine Demonstration include: 

• Abt Associates, Inc.: "Cost Effectiveness Study of 
Medicare Coverage of Influenza Vaccine, Final 
Report," May 2, 1995. 



14 



Theme 3: Meeting the Needs of Vulnerable Populations 



• Hannoun, C, Ruben, F., Klenk, H., et al., eds.: "Options 
for the Control of Influenza II: Proceedings of the 
International Conference on Options for the Control of 
Influenza, Courchevel, 27 September-2 October, 1992." 
Elsevier Science Publishers, B.V., Amsterdam, p. 468, 
1993. 

• Centers for Disease Control: "26th National 
Immunization Conference Proceedings." Atlanta, 
p. 214, 1993. 

• Centers for Disease Control: "27th National 
Immunization Conference Proceedings." Atlanta, 
p. 214, 1994. 

• Centers for Disease Control: "Final Results: Medicare 
Influenza Vaccine Demonstration-Selected States, 
1988-1992." Morbidity- and Mortality Weekly Report 
Volume 42, Number 31, pp. 601-604, 1993. 

92-069 Evaluation of the Demonstration for Improving 
Access to Care for Pregnant Substance Abusers 

Project No.: 500-92-0049 

Period: September 1 992— September 1997 

Funding: $2,131,844 

Award: Contract 

Principal 

Investigator: Embry Howell, Ph.D. 

Awardee: Mathematica Policy Research, Inc. 

P. O. Box 2393 

Princeton, NJ 08543-2393 
HCFA Project Suzanne Rotwein, Ph.D. 
Officer: Division of Health Information and 

Outcomes 

Description: The awardee is conducting an evaluation of 
the demonstration to improve access to Medicaid care for 
pregnant substance abusers. The demonstration is being 
implemented in Maryland, Massachusetts, New York, 
South Carolina, and Washington. The purposes of these 
projects are to improve outreach and assessment; expand, 
integrate, and coordinate program services; and improve 
client case management. The objective of the evaluation is 
to assess the effectiveness of interventions that are 
included in the demonstration projects. The evaluator will 
be responsible for reporting on the implementation 
process of the demonstration and on the demonstration's 
effect on access to prenatal care, substance abuse 
treatment services, and other relevant services. The 
evaluation will assess the effects of services on the health 
of drug-addicted pregnant women, any prevention or 
reduction of short-term impairments to their infants, and 
the impact on birth outcomes. The evaluation also will 
compare the cost of substance abuse treatment in 
residential facilities versus ambulatory care facilities. 

Status: The awardee has prepared a final evaluation 
design and data collection instrument and has 
implemented data collection. Site visits are being used to 



assess the status of the implementation of the 
demonstration, negotiate with providers for implementing 
the survey, and collect data for the process analysis. The 
final report is due in September 1997. 

95-028 Evaluation of the Diamond State Health Plan 

(Formerly, Evaluation of the Demonstration Entitled 
Delaware Health Care Partnership for Children) 

Project No.: 500-92-0033 

Period: September 1 994-September 1999 

Funding: $ 498,035 

Award: Delivery Order in Master Contract 

Principal 

Investigator: James S. Lubalin, Ph.D. 

Awardee: Health Policy Research Program 

Research Triangle Institute 
1615 M Street, NW, Suite 740 
Washington, DC 20036-3209 

HCFA Project Joan Peterson, Ph.D. 

Officer: Office of State Health Reform 

Demonstrations 

Description: This evaluation is being conducted by 
Research Triangle Institute (RTI) and its subcontractor, 
Health Economics Research, Inc. (HERI). The original 
purpose of the contract was to evaluate the Delaware 
Health Care Partnership for Children, specifically the 
effectiveness of the demonstration in reaching its goal of 
improving access to and the quality of health care services 
delivered to Medicaid-eligible children in a cost-effective 
way. The State believed that by enrolling children into a 
managed-care system operated by the Nemours 
Foundation, they would reap the benefits of a higher level 
of coordinated care, while the State, and in turn the 
Federal Government, would benefit from lower Medicaid 
costs. In May 1996, RTI/HERI requested a modification to 
their contract to focus more generally on the impacts of 
the Delaware State Health Plan (DSHP) on children, 
including children with special health care needs (the 
original evaluation had been limited to the Nemours 
Children's Clinics). The goal of the evaluation was 
broadened to assess whether this section 1115 
demonstration's objective of increased access to high- 
quality, cost-effective care for Medicaid children is being 
met. In May 1996, RTI/HERI also requested a 2-year, 
no-cost extension (through September 29, 1999). 

Status: RTI/HERI are in the third year of the evaluation. 
Several methodologies are being employed: site visits, 
focus groups, and administrative data analysis. One site 
visit was conducted in May 1996, and addressed issues 
pertaining to the early stages of implementation of the 
DSHP. A second site visit will take place in 1998, and 
will address qualitative impacts of the demonstration on 
access to care, quality of care, and satisfaction with care, 
as well as implementation issues that may be encountered 



Theme 3: Meeting the Needs of Vulnerable Populations 



115 



in the later stages of the demonstration. Key findings from 
the second site visit will be presented in a substantive 
progress report. The final case study results will be 
synthesized in the draft final report. Focus groups will be 
conducted by RTI staff in 1997. A summary of the focus 
groups will be presented in the second interim report. The 
administrative data analysis will rely on eligibility/ 
enrollment data and claims/encounter data gathered by the 
State. Five analytic areas will be pursued: enrollment, 
access to care, quality of care, progam costs, and the 
impact of managed care on children with chronic illness. 
The final report for the evaluation is due September 30, 
1999. Two interim annual reports are due on September 
30. 1996 and September 30, 1997. 

92-024 Evaluation of the Maryland Access to 
Care Demonstration: Managed Care for 
Medicaid Recipients 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-99 142/3 

February 1992-March 1996 

$ 225,275 

Cooperative Agreement 

Julie A. Schoenman, Ph.D. 

The People-to-People Health 

Foundation, Inc. 

Center for Health Affairs 

7500 Old Georgetown Road, Suite 600 

Bethesda, MD 20814-6133 

Paul J. Boben, Ph.D. 

Office of State Health Reform 

Demonstrations 



Description: The awardee will evaluate the Maryland 
Access to Care (MAC) demonstration, which became 
operational in December 1991, and had nearly 110,000 
Medicaid recipients enrolled as of April 1992. The 
demonstration will eventually cover about two-thirds of 
all Medicaid recipients. The targeted population will be 
Aid to Families with Dependent Children recipients, 
Supplemental Security Income (SSI) recipients, and Sixth 
Omnibus Budget Reconciliation Act eligible children. The 
MAC program is mandatory for recipients in the MAC- 
eligible categories. The program matches MAC recipients 
with a primary medical provider (PMP) that acts as the 
recipient's gatekeeper to the health care system. These 
PMPs continue under standard fee-for-service 
reimbursement systems but, to encourage their 
participation, Medicaid fees for primary care services 
have been increased by an average of 50 percent. 
Specialists are reimbursed for non-emergency specialty 
care provided to MAC patients only if these services are 
referred by the patients' PMPs. The evaluation will 
employ a pre-post-test comparison and a post-test 
description of program operations. The data to be used 



will primarily be Medicaid enrollment and claims files 
and provider surveys. 

Status: A final report received from Project Hope, is 
currently under review. 

91-015 Evaluation of the Medicaid Extension 
Demonstrations (Formerly, Evaluation of the Medicaid 
Expansion Demonstrations) 



Project No.: 


500-87-0030TO10 


Period: 


June 1991-June 1995 


Funding: 


$ 927,357 


Award: 


Technical Support: Evaluation of 




Demonstrations 


Principal 




Investigator: 


David Kidder, Ph.D. 


Awardee: 


Abt Associates, Inc. 




55 Wheeler Street 




Cambridge, MA 02138-1168 


HCFA Project 


Paul J. Boben, Ph.D. 


Officer: 


Office of State Health Reform 




Demonstrations 


Mandate: 


Omnibus Budget Reconciliation A 



of 1989 (Public Law 101-239) 

Description: For this project, the awardee will design and 
conduct the evaluation of three demonstrations mandated 
under section 6407 of the Omnibus Budget Reconciliation 
Act of 1989. The awardee will evaluate alternative models 
for extending health insurance coverage to children under 
20 years of age who lack insurance. The States conducting 
the demonstrations are Florida, Maine, and Michigan. 
Each State will use a different strategy for providing the 
new coverage. Florida will test the effectiveness of 
marketing a school-based affordable insurance package 
that delivers services through a managed-care network. 
Maine will conduct a statewide program that subsidizes 
comparable private employer-based group coverage, 
where such insurance is shown to be cost-effective. 
Michigan will test the effectiveness of a public/private 
partnership between the State and Michigan Blue Cross 
and Blue Shield, using donated funds to subsidize a 
mainstream outpatient insurance package. The evaluation 
will determine the effect of these demonstrations on 
various outcome and process measures of access to care, 
private insurance coverage, and cost of care. Methodology 
to be used will take into account the distinctiveness of the 
three demonstrations, while incorporating a strategy that 
will allow for comparisons between programs in terms of 
performance in penetrating the eligible population. Case 
studies will be coupled with the analysis of program data 
to describe the structure and processes of the 
demonstrations. In addition, primary data will be 
collected through surveys of both program participants 



116 



Theme 3: Meeting the Needs of Vulnerable Populations 



and controls. Separate analyses of program costs and 
program effectiveness will be included. 

Status: A draft final report has been received from the 
contractor. 

92-064 Evaluation of the Medicaid 
Uninsured Demonstrations 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 

Officer: 



Mandate: 



500-92-0062 

September 1 992-September 1997 

S 1.313.458 

Contract 

Margo L. Rosenbach, Ph.D. 

Health Economics Research, Inc. 

300 Fifth Avenue, 6th Floor 

Waltham. MA 02154 

James P. Hadley 

Office of State Health Reform 

Demonstrations 

Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 



Description: The purpose of this contract is to design and 
conduct the evaluation of three demonstration projects 
being conducted in Maine. South Carolina, and 
Washington State. These demonstrations, implemented in 
response to a congressional mandate under section 4745 
of the Omnibus Budget Reconciliation Act of 1990. are 
intended to test the effect of allowing States to extend 
Medicaid coverage to low-income families. Evaluation 
contract deliverables will include a series of annual 
reports, an interim and a final Report to Congress, and a 
final evaluation report. The evaluator will examine within 
and between site processes and outcomes, including: 

• Ability of the programs to enroll significant numbers of 
eligible persons. 

• Conditions under which eligible persons and their 
families are willing to participate in such programs, 
given their scarce financial resources. 

• Ability of the programs to induce adequate numbers of 
providers to ensure the availability of necessary- services 
at appropriate levels of utilization. 

• Willingness of employers to participate in the programs 
and the conditions under which they do or do not 
choose to do so. 

• Program's effect on service utilization and health 
outcomes of participants. 

• Cost effectiveness of such programs for the various 
public and private interests. 

• Extent to which the demonstration's interventions could 
be applied nationally to assist in achieving program 
goals. 

Status: The evaluator has conducted two sets of site visits, 
the first shortly after implementation and the second prior 



to the projects' ending dates, and has produced a final 
case-study report which presents findings from these site 
visits. The site visits, along with surveys of the covered 
populations (which will provide information on 
participants' health status, reasons for enrolling in the 
demonstration, and satisfaction with the programs) and 
use and cost data from the demonstration sites will 
provide the basis for the final report that is expected 
September 1997. 

94-127 Evaluation of the Oregon 
Medicaid Demonstration 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 

Officer: 



500-94-0056 

October 1994-September 

S 4,433.954 
Contract 



999 



Margo L. Rosenbach. Ph.D. 

Health Economics Research, Inc. 

300 Fifth Avenue, 6th Floor 

Waltham, MA 02154 

Paul J. Boben, Ph.D. 

Office of State Health Reform 

Demonstrations 



Description: The objectives of the Oregon Medicaid 
Reform Demonstration are to increase the number of 
individuals with access to affordable health care services 
and to contain State and Federal expenditures for health 
care. Under the demonstration. Medicaid coverage is 
made available to all State residents with family incomes 
less than or equal to the Federal poverty level (FPL). Two 
distinct strategies are used to generate the program 
savings needed to support the expanded enrollee 
population. The Medicaid benefit package is restructured 
by establishing a prioritized list of conditions and related 
treatments (CT pairs), limiting coverage to a pre- 
established number of CT pairs, and expanding the use of 
managed care for the delivery of Medicaid services. The 
demonstration began operation on February 1, 1994, and 
is scheduled to run for 5 years. The objectives of the 
evaluation are to determine the impact of the 
demonstration on access to care, quality of care, enrollee 
satisfaction, and the cost of care, for both new enrollees 
and those previously enrolled in Medicaid. To the extent 
possible, the impact of the prioritized list and the 
increased use of managed care will be identified 
separately. Other areas of interest include the impact of 
the demonstration on the number of uninsured in the 
State, provider participation and satisfaction, and the 
number of private employers who offer health insurance 
as a fringe benefit. The evaluation also will assess 
whether the concepts being tested in Oregon can be used 
in other States. 



Theme 3: Meeting the Needs of Vulnerable Populations 



117 



As initially conceived, the scope of the evaluation was 
restricted to Phase I of the demonstration, in which only 
Aid to Families with Dependent Children (AFDC) and 
AFDC-related Medicaid recipients, as well as individuals 
with incomes under 100 percent of the FPL made eligible 
by the demonstration, would participate. In September 
1995. the contract was modified to provide for additional 
analyses focusing on the experience of the aged, blind, 
and disabled Medicaid recipients who enrolled in 
managed-care plans under Phase II of the demonstration. 
The new analyses will be similar to those described above 
for the Phase I evaluation. In addition to Medicaid claims 
and encounter data, the evaluator will make use of 
disability data furnished by the Social Security 
Administration, as well as disability-related databases 
maintained by the State. The portion of the evaluation 
focusing on disabled recipients is sponsored jointly by the 
Health Care Financing Administration and the Office of 
the Assistant Secretary for Planning and Evaluation. 

Status: The baseline survey of recipients was sent by mail 
in May 1996; a second mailing was sent in July and a 
follow-up postcard in August. Responses continue to come 
in from survey recipients. Work continues on draft survey 
instruments for adult and child recipients, recipients with 
tracer conditions, and medical providers. The evaluator 
has received a complete year of encounter data from the 
State, for calendar year (CY) 1994. and much of the 
encounter data for CY 1995. They are preparing a report 
on the completeness and quality of the data, which is 
anticipated shortly. In September 1996, the evaluator 
submitted their draft report, which is under review. 

94-126 Evaluation of the State Medicaid Reform 
Demonstrations: Mathematica Policy Research, Inc. 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-94-0047 

September 1 994— September 

$ 5,636,584 

Contract 



999 



Judith Wooldridge 

Mathematica Policy Research, Inc. 

600 Maryland Avenue, SW., Suite 550 

Washington, DC 20024-2512 

James P. Hadley 

Office of State Health Reform and 

Demonstrations 



Description: Mathematica was awarded this contract to 
evaluate five State Medicaid reform demonstrations: 
Hawaii's Health QUEST, Rhode Island's RIteCare, and 
Tennessee's TennCare, with two other States that were to 
be added as their waivers are approved. 

1 he evaluator is conducting State-specific and cross-State 
analyses of demonstration impacts on utilization, 
insurance coverage, public and private expenditures, 



quality, access, and satisfaction. Analyses of all groups 
will, where possible, be stratified by age, income, 
geographic location, and other relevant demographic 
variables. Data will come from site visit interviews with 
providers, advocacy groups, and State officials; 
participant surveys; State Medicaid Management 
Information Systems and encounter data; hospital 
discharge data; routine cost reports from the State and 
providers; vital records; and secondary data sources such 
as the area resource file and current population survey. 

During 1996, two important design and funding additions 
were made to the project through interagency cooperative 
agreements. The Assistant Secretary for Planning and 
Evaluation contributed $1.2 million to enhance the 
evaluation's examination of the demonstrations' impacts 
on the disabled, and the Substance Abuse and the Mental 
Health Services Administration contributed an additional 
$400,000 to enhance the evaluation's assessment of the 
demonstrations' impacts on mental health and substance 
abuse service users. 

Status: During the first year of the evaluation, the 
contractor worked to refine the evaluation design; 
conducted site visits to Hawaii, Tennessee, and Rhode 
Island; and began an examination of the quality of 
encounter data being collected by these States. Oklahoma 
and Maryland have been identified as the two additional 
States to be included in the evaluation. The evaluator has 
produced a First Annual Report which details the 
implementation and early operational experiences of 
Hawaii, Tennessee, and Rhode Island. They are currently 
involved in refining the survey of participants and 
comparison groups that is due to be administered during 
1997 and working with early encounter data submissions 
from the States to build the files that will form the basis of 
future use, cost and quality analyses. In addition to annual 
reports focusing on findings from the previous year's 
activities, there will be a final report that is due 
September 30, 1999. 

95-052 Evaluation of the State Medicaid Reform 
Demonstrations: Urban Institute 

Project No.: 500-95-0040 

Period: September 1995-September 2000 

Funding: $ 5,959,408 

Award: Contract 

Principal 

Investigator: Stephen Zuckerman, Ph.D. 

Awardee: Urban Institute 

2100 M Street, NW. 

Washington, DC 20037 
HCFA Project Edward T. Hutton, Ph.D. 
Officer: Office of State Health Reform 

Demonstrations 



US 



Theme 3: Meeting the Needs of Vulnerable Populations 



Description: This contract will evaluate five Medicaid 
health reform demonstrations: Ohio's OhioCare, 
Minnesota's MinnesotaCare, the County of Los Angeles, 
and two additional States. The additional States will be 
determined by consideration of the timing of the 
demonstration's implementation. 

The evaluator will conduct State-specific and cross-State 
analyses of demonstration impacts on use, insurance 
coverage, public and private expenditures, quality, access, 
and satisfaction. Analyses of all groups will, where 
possible, be stratified by age, income, geographic location, 
and other relevant demographic variables. Data will come 
from site visit interviews with providers, advocacy groups, 
and State officials; participant surveys; State Medicaid 
Management Information Systems and encounter data; 
hospital discharge data; routine cost reports from the 
State and providers; vital records; and secondary data 
sources, such as the area resource file and Current 
Population Survey. 

Status: The contract was awarded at the end of 
September 1995. The first annual report is expected 
January 31, 1997, with subsequent annual reports 
expected in 1997, 1998, and 1999. The final report is due 
September 30, 2000. The contractor has submitted a draft 
evaluation design report and conducted site visits, which 
in Minnesota included focus group sessions. The first 
annual report will include summary information from the 
site visits and other communications with the sites. 

92-037 Evaluation of the Utah Prepaid Mental Health 
Plan: Coordinated Care Systems as Alternatives to 
Traditional Fee for Service 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-90035/5 

May 1992-December 1995 

$412,154 

Cooperative Agreement 

Jon Christianson, Ph.D. 

University of Minnesota 

1100 Washington Avenue South 

Minneapolis, MN 55415-1226 

Paul J. Boben, Ph.D. 

Office of State Health Reform 

Demonstrations 



Description: The awardee will evaluate Utah's 
implementation of a mental health maintenance 
organization for its Medicaid beneficiaries. Under a 
section 1915 waiver from the Health Care Financing 
Administration, the State has signed contracts with three 
community mental health centers to provide mental health 
services to all Medicaid beneficiaries in their catchment 
areas, which include 52 percent of all Medicaid 
beneficiaries in Utah, in return for capitated payments. 
The State hopes that this prepaid program will control the 



rapidly inflating costs of inpatient mental health care in 
its Medicaid program, while improving patient outcomes. 
The evaluation will examine how capitated rates are 
determined, beneficiaries are enrolled, and contracts are 
enforced. It also will examine the impact of the 
demonstration on the use and cost of mental health care 
received by Medicaid beneficiaries. The evaluation will 
use a mix of qualitative and quantitative research 
methodologies. Qualitative research methods will be used 
to assess the impact of Medicaid operations and the 
payment structure. The use and cost analysis will use 
quantitative research methodologies based on Medicaid 
claims and payment data. The National Institute of 
Mental Health is funding a companion study of the Utah 
program to examine the impact of the demonstration on a 
subgroup of high-risk beneficiaries — those individuals 
diagnosed as suffering from schizophrenia. 

Status: In March 1996, the following deliverables were 
received from the grantee: "Outcomes For Medicaid 
Beneficiaries With Schizophrenia in the Utah Prepaid 
Mental Health Plan," and "The Evolution of the Utah 
Prepaid Mental Health Plan In Its First Three Years: 
Operational Issues For Medicaid and Contracting 
Community Mental Health Centers (CMHCs)." A final 
report on the impact of the demonstration on utilization of 
services by all Medicaid beneficiaries and Medicaid 
expenditures, to be based on claims data from Medicaid 
and the CMHCs, is anticipated shortly. 

93-076 Examination of the Medicaid 
Expansions for Children 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-93-0042 

September 1993-March 1998 

$ 648,416 

Contract 

Genevieve Kenney, Ph.D. 

Urban Institute 

2100 M Street, NW. 

Washington, DC 20037 

Judith A. Sangl, Sc.D. 

Division of Health Information and 

Outcomes 



Description: This project will focus on Medicaid 
eligibility expansions for children. These expansions were 
legislated as part of the Omnibus Budget Reconciliation 
Acts of 1989 and 1990. Analyses on the impact of the 
expansions include examination of enrollment and 
expenditure trends from 1988 to 1992; assessment of the 
extent to which the expansions penetrated the target 
population; and multivariate analysis to examine the 
impact of State policies and the eligibility group on 
enrollment, expenditures, and utilization of services. 
Steps to examine access to care and utilization of services 



Theme 3: Meeting the Needs of Vulnerable Populations 



119 



include the development of a theoretical model, an 
analysis plan, and items that could be incorporated into 
an established national survey. 

Status: The following tasks have been completed or 
begun: 

• A review of proposed health reform bills and how they 
affect children. 

• A report, "Toward Evaluating the Effects of the 
Medicaid Eligibility Expansions on Low-Income 
Children's Access to Care and Service Use." This 
report outlines a theoretical model of children's health 
care use and uses the theoretical model to identify data 
that would be required to evaluate the effects of the 
Medicaid policy expanding eligibility to low-income 
children on their access to care and service use. 

• Enrollment and expenditure tables to examine trends 
between 1987 and 1992 and to compare enrollment 
groups for the four Tape-to-Tape States of California, 
Georgia, Michigan, and Tennessee. These allow an 
assessment of enrollment and expenditure patterns as 
they vary over time and across groups of enrollees. 

• A report, "The Effects of Medicaid Expansions on 
Insurance Coverage of Children," consists of an 
analysis of changes in insurance coverage using the 
Urban Institute's TRIM 2 microsimulation model. The 
report was published in The Future of Children, 
Volume 6, Number 7, Spring 1996. 

• Data file construction and variable specification to 
estimate State-level enrollment models for children and 
individual-level models of health care expenditures, 
access, and utilization for children. 

93-002 Expanded Cross-Cutting Evaluation of 
Medicare Prevention Demonstrations Under the 
Consolidated Omnibus Budget Reconciliation Act 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



500-92-0057 
October 1992- 
$ 357,699 
Contract 



March 1995 



David Kidder, Ph.D. 
Abt Associates, Inc. 
55 Wheeler Street 
Cambridge, MA 02138-1168 
Deborah C. Van Hoven 
Office of State Health Reform 
Demonstrations 

Consolidated Omnibus Budget 

Reconciliation Act of 1985 

(Public Law 99-272) 

Omnibus Budget Reconciliation Act of 

1990 (Public Law 101-508) 

Description: Abt Associates, Inc. conducted a cross- 



HCFA Project 
Officer: 



Mandates: 



cutting evaluation of the five Medicare prevention 
demonstrations, mandated by the Consolidated Omnibus 
Budget Reconciliation Act (COBRA) of 1985, which 
tested the effectiveness of providing disease prevention 
and health promotion services to Medicare beneficiaries. 
Congress stipulated that the preventive health service 
package to be made available was to include health 
screening, health risk appraisals, immunizations, and 
counseling and instruction in diet and nutrition, stress 
reduction, exercise programs, sleep regulation, injury 
prevention, substance abuse and mental disorders 
prevention, self-care (including medication use), and 
smoking cessation. 

Status: The contract for a cross-cutting evaluation was 
initially awarded September 30, 1987, and in May 1988, 
cooperative agreements were awarded to five schools of 
public health to implement the demonstration. Waivered 
services were provided between May 1989 and 
April 1991. A preliminary Report to Congress was 
submitted in July 1989. OBRA 1990 extended the 
demonstration projects, through April 1994, to provide for 
a longer-term evaluation of the preventive services that 
were provided, and added an interim report, which was 
submitted to Congress in September 1993, and a final 
report, which is to include a comprehensive evaluation of 
the long-term effects of the demonstration. The original 
evaluation contract was modified in October 1992 as a 
result of the OBRA 1990 extension. The final report is 
expected to be submitted to Congress in early 1997. 

90-018 Financing of Acquired Immunodeficiency 
Syndrome and Acquired Immunodeficiency 
Syndrome-Related Complex Treatment Costs by 
Medicaid and Medicare 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-99522/3 
May 1990-Decemberl996 
$ 648,985 
Cooperative Agreement 

Julia Hidalgo 

Maryland Department of Health 

and Mental Hygiene 

Center for AIDS Services, Planning, 

and Development 

201 West Preston Street 

Baltimore, MD 21201 

Penelope L. Pine 

Division of Health Information and 

Outcomes 



Description: The State of Maryland has developed a 
longitudinal database focusing on human immuno- 
deficiency virus (HlV)-infected people from 1981 through 
1992. The project is expected to provide related illness 
information on the extent to which patient, provider, and 



120 



Theme 3: Meeting the Needs of Vulnerable Populations 



payer characteristics influence cost and use of health 
services on expenditures in Maryland under the Medicaid 
and Medicare programs. Four major aspects to the study 
are to maintain the data systems of the Maryland Human 
Immunodeficiency Virus Information System as required 
to measure program use and financing; to compare and 
refine three different disease-staging approaches for 
predicting resource consumption and treatment outcomes 
during the course of the HIV disease; to retrospectively 
assess health services utilized by pediatric, adolescent, 
and adult patients with HIV; and to use annual 
utilization, reimbursement, and financing data to measure 
trends. 

Status: The project is in its final year. Medicare data are 
being developed and analyzed. Calendar year 1992 
Medicaid data have been analyzed. The three disease- 
staging approaches and classification models under study 
are the Severity Index for Adults with AIDS (SIAA), the 
Severity Classification for AIDS Hospitalizations 
(SCAH), and the Centers for Disease Control (CDC) 
Disease Classification System. SCAH has been applied to 
a longitudinal data set of adults with acquired 
immunodeficiency syndrome (AIDS) hospitalizations for 
1983 and 1989 to predict long-term survival. Currently, 
SIAA and the CDC classification are being assessed and 
compared to SCAH to predict survival and health services 
utilization. Development of the Medicare data is under 
way. These papers have been presented at various 
professional meetings: 

• Hildalgo, J.: "Medicaid, Does Enrollment Ensure 
Access to Care for Persons with AIDS?" AIDS Health 
Services Research Conference, December 1991. 

• Hildalgo, J.: "Trends in the Public Financing of AIDS 
1985-1990." AIDS Health Services Research 
Conference, December 1991. 

• Hildalgo, J., Boreta, J. C, Beardsley, R., Chaisson, R., 
and Moore, R.: "Epidemiological Monitoring of AIDS 
Patients: The Maryland Experience." George 
Washington University Meeting on Drug Development 
in the 1990's: The Legacy of AIDS. 

Publications available include: 

• Hildalgo, J.: "Development and Application of 
Statewide Acquired Immunodeficiency Syndrome 
Information Systems in Health Services Planning and 
Evaluation." Evaluation and Program Planning, 
Volume 13, pp. 39-46, 1990. 

• Hildalgo, J.: "Development of a Model Longitudinal 
Database to Measure Outcomes and Quality of Care 
Among Persons with AIDS." Quality Review Bulletin, 
pp. 355-363, October 1990. 

• Moore, R. D., Hildalgo, J., Sugland, B. W., and 
Chaisson, R.: "Zidovudine and the Natural History of 
Acquired Immunodeficiency Syndrome." 

The New England Journal of Medicine, Volume 324, 
Number 20, pp. 1412-1416, May 16, 1991. 



93-070 Federally Qualified Health Centers 

Project No.: 500-92-0037/03 (for Medicaid 

Demonstration and Evaluation Support) 

Projects: Master Contract 

Period: September 1993-August 1996 

Funding: $ 283,465 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Judith Wooldridge 

Awardee: Mathematica Policy Research, Inc. 

(See page 19) 

Project Alisa Adamo 

Officer: Office of State Health Reform 

Demonstrations 

Description: The Office of Research and Demonstrations 
awarded a contract in September 1 993 to assess how the 
provision of health services through federally qualified 
health centers (FQHCs) has influenced access to, use of, 
and cost of health services to Medicare and Medicaid 
beneficiaries. The first phase of the contract determined 
the feasibility of doing a valid quantitative study. FQHC 
service-use data are not readily available in a central 
database. Many of the research questions needed detailed 
service-specific data in order to be answered. By the end 
of the first phase, the contractors finalized the study 
design and were ready to begin conducting the 
quantitative study (the second phase). 

The study examined the impact of the FQHC program on 
patients, health centers, and State Medicaid programs, 
looking primarily at changes between 1 989 (before the 
program was implemented) and 1 992 (when the program 
was fully implemented). Contrary to what was originally 
envisioned, the impact of FQHCs on the Medicare 
program was not assessed in this study. It sought to 
answer the following questions: 

• Did the FQHC policies attain the legislative goals of 
increasing Medicaid patients and revenue for health 
centers and increasing their ability to serve the 
uninsured? 

• What type of Medicaid enrollees use FQHCs? How 
have the number and characteristics of Medicaid users 
changed since the implementation of the FQHC 
program? 

• What are the utilization patterns of FQHC users and 
how have they changed? 

• What are the differences between Medicaid enrollees 
who use FQHCs and those who do not in their 
characteristics or service use? 

• How much of the total ambulatory care of FQHC users 
is received at the FQHC, compared with other settings? 

• How much does the FQHC program cost the Medicaid 
program? 



Theme 3: Meeting the Needs of Vulnerable Populations 



121 



• How much of the change in Medicaid payments to 
health centers between 1989 and 1992 is due to the 
FQHC-related policies and how much is due to normal 
program growth or cost increases? 

The study analyzed changes in Medicaid services, users, 
and payments for health centers in California and 
Michigan before and after FQHC policies were 
implemented (1989 and 1992). The two main data sources 
were — the detailed Medicaid claims and eligibility 
databases for the two States; and, the annual reports filed 
by health centers with the Federal Government. 

Status: The final report was submitted in August 1996. 
The study showed that FQHC policies partly met their 
goals. Health centers in California and Michigan 
dramatically increased Medicaid users and Medicaid 
revenue between 1989 and 1992. However, the uninsured 
users did not increase at the level of Medicaid users, and 
in some instances the uninsured users actually decreased. 

The study showed that the core Medicaid recipients seen 
at FQHCs in California and Michigan are low-income 
mothers and children (particularly pregnant women). 
Most of the Medicaid services provided by the FQHCs are 
general and preventive primary health care, including 
dental services. Other specialized services such as mental 
health care are usually obtained from other providers. 
The study indicated that FQHCs, as a result of the 
legislation, are paid roughly twice as much as other 
physicians. The authors note that these payment 
differences do not reflect the total cost impact of FQHCs 
on State Medicaid programs. It was beyond the scope of 
this study to examine the overall cost effectiveness or 
quality of care at health centers. 

The study concluded with some policy discussion about 
what would happen if FQHC cost-reimbursement was 
eliminated. 

94-125 Florida Health Security (FHS) 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00025/4 

September 1 994-September 1999 

Waiver-only Project 

Tom Wallace 
Florida's Agency for 
Health Care Administration 
The Atrium, Suite 301 
325 John Cox Road 
Tallahassee, FL 32303-4131 
Alisa Adamo 

Office of State Health Reform 
Demonstrations 



Description: The Florida Health Security (FHS) program 
will build on the State's managed competition model. It 
aims to test the extent to which Federal and State 
assistance will allow employers to provide coverage to 
employees and their dependents in a voluntary market. 
FHS is a voluntary, employer-based, discounted premium 
program designed to provide access to private health 
insurance for working uninsured Floridians. FHS will 
provide health insurance for 1.1 million uninsured 
Floridians with gross income at or below 250 percent of 
the Federal poverty level (certain individuals are 
ineligible for FHS, e.g., Medicaid and Medicare eligibles, 
individuals who have been insured in the previous 
12 months). 

The FHS program is distinctly separate from the State's 
traditional Medicaid program. The traditional Medicaid 
program will not be affected by the FHS program. 
However, a series of reforms will be occurring in the 
State's traditional Medicaid program, and these reforms 
should provide most of the financing for the FHS 
program. The reforms include mandating managed care 
for all traditional Medicaid eligibles and eliminating the 
medically needy program. Most medically needy 
individuals will be eligible for FHS; those who are not 
will be grandfathered into the traditional Medicaid 
program. 

Under FHS, health plans (indemnity and health 
maintenance organization) will be offered by accountable 
health partnerships and administered by a network of 
community health purchasing alliances established to 
implement Florida's overall managed competition 
strategy. 

Status: The FHS program as described above cannot be 
implemented without State legislation. On July 3, 1996, 
an amendment was approved exempting four plans from 
the 75/25 enrollment composition requirement until 
July 1, 1997 as long as they maintain a 90 percent rating 
in the State's annual review of health plans. The 
amendment also stated HCFA's willingness to consider 
partial year exemptions for other plans whose 3-year 
75/25 waivers expire prior to July 1, 1997, and who score 
above 90 percent in the State's annual review of health 
plans. The State will be expanding quality assurance 
requirements on the plans, expanding access in rural 
areas, and testing the feasibility of collecting and 
verifying 100-percent encounter data. 

94-068 Florida Welfare Reform: 
Family Transition Program 

Project No.: 1 l-W-0001 1/4 

Period: January 1 994-December 200 1 

Award: Waiver-only Project 



122 



Theme 3: Meeting the Needs of Vulnerable Populations 



Principal 

Investigator: 

Awardee: 



Project 
Officer: 



H. James Towey 

Florida Department of Health and 

Rehabilitative Services 

1317 Winewood Boulevard 

Tallahassee, FL 32399-0700 

Alisa Adamo 

Office of State Health Reform 

Demonstrations 



Description: This demonstration has waivers from the 
Health Care Financing Administration and the 

Administration for Children and Families to: 

• Allow two-parent families to have the same eligibility 
criteria as single-parent families and disregard the 
income of stepparents for the first 6 months of receipt of 
Aid to Families with Dependent Children (AFDC). 

• Impose financial sanctions on families if children do 
not attend school regularly or are not immunized. 

• Limit the receipt of AFDC benefits to 24 months in any 
60-month period. 

• Require recipients whose youngest child is over 

6 months of age to participate in the Jobs Opportunity 
and Basic Skills program. 

• Increase disregard of earnings and asset limits. 

• Increase transitional child-care benefits. 

• Eliminate quarterly income reporting during the 
Medicaid transition benefit period, but require 
recipients to report income increases. 

Medicaid waivers were required in order to eliminate the 
need for income reporting during the transition benefit 
period. 

Status: The program was implemented in March 1994 in 
two counties, and the demonstration area was expanded to 
include a total of six counties in March 1995. With the 
August 22. 1996 enactment of the Personal Responsibility 
and Work Opportunity Reconciliation Act of 1996 
(PRWORA), it is anticipated that the Title IV-A 
component of this demonstration will be modified. 
However, the impact of the PRWORA is being analyzed. 

93-062 Hawaii QUEST 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



ll-W-00001 9 

April 1994-March 1999 

Waiver-only 

Grant 

Reuben Shimazu, Acting Director 

Med QUEST Division 

Hawaii Department of Human Services 

P. O. Box 339 

Honolulu, HI 96809-0339 



HCFA Project Anne K. Wade 
Officer: Office of State Health Reform 

Demonstrations 

Description: Hawaii QUEST is a statewide project that 
creates a public purchasing pool that arranges for health 
care through capitated managed-care plans. Hawaii 
QUEST builds on Hawaii's Prepaid Health Care Act by 
integrating public and private programs to develop a more 
efficient, seamless health care delivery system for 
individuals previously served by three public programs: 
Medicaid, General Assistance, and the State Health 
Insurance Program. The project extends the Medicaid 
eligibility income limits to 300 percent of the Federal 
poverty level and provides a benefit package consistent 
with the services currently offered under Hawaii's 
traditional Medicaid program, including medical, dental, 
and behavioral health services. 

Status: Hawaii QUEST was implemented on 
August 1, 1994. Approximately 135,000 beneficiaries are 
currently enrolled in five capitated health plans and two 
capitated dental plans. The State has contracted with a 
behavioral health managed-care plan to provide 
behavioral health services to adults, while children 
requiring these services are enrolled with the Hawaii 
Department of Health, Children and Adolescents Mental 
Health Division. Enrollment in Hawaii QUEST was 
higher than originally projected for the first full 
operational year, and amendments to the demonstration 
designed to curb enrollment of the expansion population 
were approved. The amendments include the imposition 
of premiums on non-categorical individuals above the 
Federal poverty level, except pregnant women and 
children, and other cost-sharing provisions. 

In addition, in response to a pending lawsuit, the State 
requested and HCFA approved the following amendments 
in May 1996: 

• Reinstate the asset test for QUEST to mirror Hawaii's 
criteria for the aged, blind, and disabled. 

• Create a "QUEST Net" program designed as a safety 
net for those individuals losing QUEST or Medicaid 
coverage due to assets. 

• Require individuals above the poverty level, except 
pregnant women and children, to pay the full QUEST, 
or QUEST Net, premium. Approximately 10,000 
beneficiaries are currently enrolled in QUEST Net. 

Program monitoring is proceeding through an external 
quality review contract, HCFA site visits and conference 
calls, and beneficiary satisfaction surveys. A contractor is 
currently developing the encounter data collection system. 
The State plans to bring the aged, blind, and disabled 
population into QUEST in July 1997. 



Theme 3: Meeting the Needs of Vulnerable Populations 



123 



93-095 Health Care Service Use and Expenditures 
of the Noninstitutionalized Population (Formerly, 
Long-Term Care Studies (Section 207)) 

Project No.: 500-89-0047/8 

Period: June 1 993-February 1995 

Funding: $ 148,000 

Award: Contract 

Principal 

Investigator: David Kennell 

Awardee: Lewin/VHI, Inc. 

(See page 17) 

HCFA Project Carolyn Rimes 

Officer: Division of Aging and Disability 

Description: Using data from the 1987 National Medical 
Expenditures Survey Household Component, this study 
addresses the: 

• Differences in the utilization of health care services by 
disabled and nondisabled populations. 

• Whether community-based long-term-care services and 
expenditures substitute for acute-care expenditures for 
the population using community-based long-term-care 
services and the implications for costs. 

• Medicaid asset spenddown in the community. 

• Trends in out-of-pocket expenditures and total health 
care expenditures for the elderly population with 
comparisons to the 1977 National Medical Care 
Expenditure Survey. 

Status: Analysis files have been constructed. A draft 
report has been completed. The final report is expected in 
January 1997. 

96-087 Health Services Research Activities — 
Technical Assistance, Research, Information, 
Collaboration, Networking, and Program 
Development for Historically Black Colleges and 
Universities (HBCUs) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



HCFA-IA 95-130 

September 1995-September 1997 

S 500,000 

Interagency Agreement 

Georgia Buggs 

Office of Minority Health 

Office of Public Health and Science 

Rockwall II Bldg., Ste. 1000 (10th Fir.) 

5600 Fishers Lane 

Rockville, MD 20857 

Richard Bragg 

Division of Aging and Disability 



Description: The purposes of this interagency agreement 
arc for the Health Care Financing Administration (HCFA) 
to increase the research capacity of HBCUs to conduct 



health services research using HCFA data by: 

• Developing ties between HBCU researchers and HCFA 
staff. 

• Fostering inter-university communications regarding 
minority health care issues. 

• Developing a Research Network among HBCUs. 

• Encouraging researchers to work individually or 
collaboratively on promoting research aimed at 
developing a better understanding of African- American 
health-care-service issues. 

• Develop and/or enhance the administrative 
infrastructure of participating Office of Sponsored 
Programs at 12 selected HBCUs to assist their 
institutions to develop the capacity to successfully 
compete for Federal/non-Federal funding. 

Status: Project is ongoing. 

96-006 Illinois MediPlan Plus Demonstration 

Project No.: 1 l-W-00091/5 

Period: For the period of five years, 

beginning the first day of the month 
of effective enrollment. 

Award: Waiver-only Project 

Principal 

Investigator: Robert W. Wright 

Awardee: Illinois Department of Public Aid 

Jesse B. Harris Building 
1 00 South Grand Avenue East 
Springfield, IL 62762-0001 

HCFA Project Gina P. Clemons 

Officer: Office of State Health Reform 

Demonstrations 

Description: The goal of the demonstration is to increase 
access and quality of health care for the State's 
1.1 million Medicaid beneficiaries and limit rising costs 
through the increased use of managed care. Illinois 
intends to contract with a mix of health maintenance 
organizations (HMOs), managed-care community 
networks (MCCNs), and enrolled managed-care providers 
that incorporate federally qualified health centers 
(FQHCs), rural health clinics, and physicians who agree 
to provide primary care case-management services. In 
addition, as a transition to managed care, for a limited 
period, community providers who are interested in 
forming a MCCN will be permitted to participate as a 
Prepaid Health Plan in order to gain incremental 
experience in operating a managed-care delivery system. 

MediPlan Plus will be implemented statewide. In areas 
where MCCN access exists to serve beneficiaries, the 
State will be given a waiver of freedom-of-choice and 
exemptions from the HMO lock-in provisions and the 
75/25 enrollment composition provision. In areas where 



124 



Theme 3: Meeting the Needs of Vulnerable Populations 



there is not sufficient MCCN access, only the waivers 
permissible through the 1915(b) program (freedom-of- 
choice) will be granted. 

Status: The State plans to have effective enrollment in 
MediPlan Plus by November 1997. 

93-042 Illinois Welfare Reform: Project Fresh Start: 
Homeless Families Stabilization Component 



Project No.: 


ll-P-90242/5 


Period: 


May 1993-June 1998 


Award: 


Waiver-only Project 


Principal 




Investigator: 


Robert W. Wright 


Awardee: 


Illinois Department of Public Aid 




100 South Grand Avenue East 




Springfield, IL 62762-0001 


Project 


Alisa Adamo 


Officer: 


Office of State Health Reform 




Demonstrations 



Description: This component of a larger demonstration 
has waivers from the Health Care Financing 
Administration and the Administration for Children and 
Families. The homeless families stabilization component 
provides one-stop shopping for services for homeless 
families who are eligible for Aid to Families with 
Dependent Children; increases the asset limit and the 
disregard of earnings in the first 2 years of employment; 
and provides a 24-month Medicaid transition benefit with 
no income limit for those families who work their way off 
welfare. 

Status: Demonstration waivers were implemented on 
July 1, 1994. In general, the demonstration had some 
difficulty in obtaining participants since the beginning. In 
order to test the hypotheses properly, an enrollment of 
600 families was required. However, only a small number 
of families enrolled in the demonstration. The State 
stopped enrollment effort in August 1995. There are still 
approximately 15 families receiving services under the 
demonstration. With the August 22, 1996 enactment of 
the Personal Responsibility and Work Opportunity 
Reconciliation Act of 1996 (PRWORA), it is anticipated 
that the Title IV-A component of this demonstration will 
be modified. However, the impact of the PRWORA is 
being analyzed. 

92-020 Impact of Complicating Diseases on 
End Stage Renal Disease Outcomes and Costs 

Project No.: 17-C-90082/3 

Period: February 1 992-December 1994 

Funding: $321,044 

Award: Cooperative Agreement 



Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandate: 



Neil Powe, M.D. 

Johns Hopkins University 

School of Medicine 

720 Rutland Avenue 

Baltimore, MD 21205 

Lawrence E. Kucken 

Division of Health Information and 

Outcomes 

Omnibus Budget Reconciliation Act 
of 1986 (Public Law 99-509) 



Description: The purpose of this project is to examine 
patient and provider characteristics associated with 
complicating diseases within the end stage renal disease 
(ESRD) population and the effects of these disease 
patterns on patient outcomes, utilization, and costs. The 
study design involves longitudinal analyses of ESRD 
patients to determine risk factors associated with the onset 
of complicating illness and outcomes such as 
hospitalization and mortality. The study period covers the 
years 1984 through 1990 and will draw upon data from 
the ESRD Program Management and Medical 
Information System and other Medicare statistical files. 

Status: The final report is currently under review. 

92-010 Impact of Medicaid Eligibility Expansions and 
Innovative Programs for Maternal Health Care 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-90 113/9 
February 1 992— December 
$ 301,000 
Cooperative Agreement 



1994 



Stephen H. Long, Ph.D. 

Rand Corporation 

1700 Main Street 

P.O. Box 2138 

Santa Monica, CA 90407-2138 

Herbert A. Silverman, Ph.D. 

Division of Payment Systems 



Description: The focus of this project is to assess the 
impact of the Medicaid eligibility expansions on the 
financing and use of health care services by all women 
and newborns in Florida, regardless of their source of 
insurance, if any. To assess the aggregate impacts of the 
changes, the analytic approach to be taken is to estimate 
the flow of funds for perinatal care before and after the 
Medicaid expansion. The two periods being compared are 
July 1988 through June 1989 (pre-expansion) and 
calendar year 1991 (post-expansion). 

Status: Because of funds received from the March of 
Dimes, the scope of the study was expanded to include an 



Theme 3: Meeting the Needs of Vulnerable Populations 



125 



analysis of pregnancy outcomes resulting from lowered 
financial barriers to prenatal care. The project has been 
completed and a report submitted. The salient findings of 
the study were: 

• The number of prenatal visits paid by the Florida 
Medicaid program increased from 466,600 in 1988-89 
to 729.700 in 1991, an increase of 56 percent. In 
1988-89, Medicaid paid 22.5 percent of all prenatal 
visits; by 1991, the Medicaid share increased to 

32.8 percent. 

• The number of deliveries in which Medicaid was the 
primary payer increased from 53,600 in 1988-89 
(25.2 percent of all deliveries) to 77,100 in 1991 
(36.1 percent of all deliveries). 

• Total payments for maternity care provided by Florida 
physicians and hospitals were $902 million in 1988-89 
and $928 million in 1991. The Medicaid share 
increased from 15.0 percent in 1988-89 to 20.2 percent 
in 1991. 

• Among mothers eligible by reason of the Medicaid 
expansions, the incidence of low- birthweight deliveries 
decreased from 67.2 per 1,000 deliveries in 1988-89 to 
60.6 per 1,000 in 1991. Among mothers with other or 
no insurance and living in areas with more than 

30 percent of the population with an income below 
150 percent of the Federal poverty level , the incidence 
of low-birthweight deliveries decreased from 72.1 per 
1,000 in 1988-89 to 68.2 per 1,000 in 1991. The 
authors claim that the Medicaid expansions in Florida 
improved outcomes for mothers made eligible for 
coverage by the expansions compared to smaller degree 
of improvement shown by low-income mothers not 
covered by Medicaid. Despite the improvements among 
mothers made eligible by virtue of the expansions, the 
improved outcomes do not reach the levels attained by 
privately insured women. 

The report is available from the National Technical 
Information Service, accession number PB96-155106. 
The price is $27.00 for a paper copy and $12.50 for 
microfiche. 

96-082 Improving Outcomes for Low-Income 
Pregnant Women: Effects of Medicaid Eligibility 
and Alternative Delivery Systems 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



360-96-30300 

June 1996-May 1998 

$ 43,998 

Task Order Contract 

Stephen H. Long, Ph.D. 

Rand Corporation 

1 700 Main Street 

Santa Monica, CA 90407-2138 



HCFA Project Penelope L. Pine 
Officer: Division of Health Information and 

Outcomes 

DescriptiomThe project will extend the database and 
analysis from a previous Health Care Financing 
Administration (HCFA), study of the 1989 Florida 
Medicaid eligibility expansions for pregnant women. This 
observational study will look at the variations in Medicaid 
eligibility and the role of different delivery systems in 
providing prenatal care to Medicaid enrollees in Florida 
over the years 1988-94. The study will estimate the: 

• Variation in birth outcomes among Medicaid 
beneficiaries using different delivery systems. 

• Effects of Medicaid eligibility and use of alternative 
delivery systems on outcomes for subgroups of low- 
income women. 

• Whether providing care directly through the public 
health system substitutes for providing public insurance 
to improve access to the private delivery system. 

Status: Vital records and Medicaid data are being 
acquired for 1992-95 and linked to the earlier study data. 

92-099 Issues in Long-Term Care Policy for the 
Disabled Elderly with Cognitive Impairment 

(Formerly, Long-Term Care Studies (Section 207)) 

Project No.: 500-89-0047/21 

Period: January 1992-March 1995 

Funding: $ 180,000 

Award: Contract 

Principal 

Investigator: David Kennell 

Awardee: Lewin/VHI, Inc. 

(See page 17) 

HCFA Project Carolyn Rimes 

Officer: Division of Aging and Disability 

Description: This study utilizes the National Long-Term 
Care (NLTC) surveys to analyze issues related to informal 
caregiving to cognitively impaired elderly people, the mix 
of formal and informal services they use, and the risk of 
institutionalization. The main question addressed is 
whether the presence of such factors as behavioral 
problems or conditions (e.g., incontinence) that imply 
special service needs affect the mix of services used or the 
risk of institutionalization. This work will be completed 
by Judith Kasper of the Johns Hopkins University School 
of Hygiene and Public Health under subcontract to 
Lewin/VHI. 

Status: The article, "Cognitive Impairment and Problem 
Behaviors as Risk Factors for Institutionalization," by 
Judith Kasper and Andrew D. Shore, describes the first 
part of this study and appears in the Journal of Applied 
Gerontology, Volume 13, Number 4, pp. 371-385, 
December 1994. The NLTC survey data were used to 



126 



Theme 3: Meeting the Needs of Vulnerable Populations 



develop a predictive model for nursing home 
institutionalization that includes cognitive functioning 
and problem behaviors in addition to more commonly 
studied indicators, such as disability. As expected, 
cognitive impairment is a risk factor for 
institutionalization, controlling for other characteristics 
such as age, living arrangement, and use of paid in-home 
care. Four problem behaviors were investigated, but only 
one, wanders/gets lost, contributed to the model. Among 
cognitively impaired persons, those who wander/get lost 
had a twofold risk of institutionalization. The findings 
suggest the need to differentiate among difficult or 
problem behaviors and to further investigate those that 
arouse concerns about safety and require extensive 
supervision as risk factors for institutionalization. The 
second part of this study examining survey data combined 
with Medicare claims is final. 

94-128 Kentucky Health Care 
Partnership Plan Amendment 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00005/4 

October 1995-October 2001 

Waiver-only Project 

John H. Morse 

Kentucky Department for 

Medicaid Services 

Cabinet for Human Resources 

Frankfort, KY 40621-0001 

Maria Boulmetis 

Office of State Health Reform 

Demonstrations 



Description: The State of Kentucky did not receive the 
necessary State legislation to implement the Kentucky 
Medicaid Access and Cost Containment demonstration, 
approved on December 9, 1993. On June 19, 1995, the 
State submitted an amendment to its proposal, entitled the 
Kentucky Health Care Partnership Plan. The amendment 
incorporates the legislature's direction to postpone 
expansion to new enrollees until the demonstration has 
been implemented and proven to be successful in 
providing quality, cost-effective care to the current 
Medicaid population. Under the amended waiver, the 
State will be divided into eight managed-care regions, 
incorporating public and private providers into a single 
network in order to provide beneficiaries with accessible, 
cost-effective care in urban and rural areas. Medicaid 
beneficiaries will be enrolled in the partnership 
designated for their area, and the benefit package will be 
consistent across all the partnerships. In areas where a 
partnership cannot be developed, the State will 
competitively bid the contract to set up a managed-care 
delivery system. 

Status: The State is expected to begin contracting with the 
partnerships in early 1997 with the Bluegrass Area being 



the first region ready for implementation. Beneficiaries are 
scheduled to receive managed-care services in 
July 1997. 

90-056 Long-Term Care Survey 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



HCFA-IA-9155 

September 1 990-February 1993 

Interagency Agreement 

Richard Sussman 

National Institute on Aging 

9000 Rockville Pike 

Bethesda, MD 20892 

Carolyn Rimes 

Division of Aging and Disability 



Description: The Office of the Assistant Secretary for 
Planning and Evaluation and the Health Care Financing 
Administration agree to transfer funds to the National 
Institute on Aging (NIA) to support an existing NIA grant 
to Duke University, Center for Demographic Studies. This 
grant is entitled, Functional and Health Changes of the 
Elderly, 1982-89. The National Long-Term Care Survey 
(NLTCS) is a detailed household survey of persons 
65 years of age or over who have some chronic functional 
impairment (90 days or more). The survey has been 
administered 3 times. The first, conducted in 1982, was 
devised as a cross-sectional survey. The second, 
conducted in 1984, added a longitudinal component to the 
sample design. The third, administered in 1989, used the 
cohorts from the previous surveys in addition to persons 
becoming 65 years of age to form a nationally 
representative sample of impaired elderly persons. To 
facilitate the use of the database, these tasks related to the 
1982, 1984, and 1989 surveys were performed under this 
agreement: 

• File linkage over the entire period 1982-89. 

• Derivation of new longitudinal sample weights. 

• Linkage of Medicare administrative records. 

• Improvement of coding by checking consistency of 
survey items. 

• Improvement in survey documentation. 

• Seminars and education. 

Status: The public use version can be obtained from 
Michigan Archives by calling (313) 763-501 1. The files 
are currently being matched with the HCFA adminis- 
trative data to verify status (i.e., Medicare status and 
mortality). NIA is planning to repeat this study in 1999. 

94-044 Longitudinal Health Care Use and 
Expenditures of Disabled Persons 



1995 



Project No.: 


500-89-0047/42 


Period: 


January 1994— June 


Funding: 


$ 143,000 


Award: 


Contract 



Theme 3: Meeting the Needs of Vulnerable Populations 



127 



Principal 
Investigator: 

Awardee: 

HCFA Project 
Officer: 



David Kennel 1 
Lewin/VHI, Inc. 

(See page 17) 

Carolyn Rimes 

Division of Aging and Disability 



Description: This project, conducted in collaboration with 
the Health Care Financing Administration, uses data from 
the Medicare Current Beneficiary Survey to examine 
health care use by persons with disabilities and the cost of 
providing these services. In this study, Medicare 
beneficiaries are categorized by different definitions of 
disability and by duration of disability. An analysis of the 
types of health care services and patterns of use for each 
subgroup is performed to determine the extent to which 
differences in such constructs are associated with 
differences in health care use and costs. This study is 
designed, in part, to provide information parallel with 
that from Lewin/VHI 's analysis of National Medical Care 
Expenditure Survey data and Duke University's analysis 
of National Long-Term Care Survey data. This work has 
been subcontracted to the Urban Institute. 

Status: A draft report has been received and reviewed. 
The final report is expected to be completed in 
December 1996. 

96-064 Maine Welfare Reform: Welfare to Work 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00084/1 

June 1996-May 2001 

Waiver-only Project 

Kevin Concannon 

Maine Department of Human Services 

State House Station No. 1 1 

Augusta, ME 04333 

Joan Peterson, Ph.D. 

Office of State Health Reform 

Demonstrations 



Description: This demonstration requires caretaker 
relatives to sign a family contract; requires participation 
in Jobs Opportunity and Basic Skills Training (JOBS), 
child support enforcement, parenting classes and health 
care services; offers a lump-sum, one-time payment in 
lieu of Aid to Families with Dependent Children (AFDC) 
for the purpose of obtaining/retaining employment; 
provides voucher payments to unmarried minor parents, 
where appropriate; limits JOBS exemptions; and expands 
eligibility for transitional child care and transitional 
Medicaid. Specifically, Welfare to Work provides an 
initial 12 months of transitional Medicaid benefits to 
individuals who become ineligible for AFDC due to 
employment resulting from upfront job search activities 
but who did not receive AFDC in 3 of the 6 months prior 
to becoming ineligible. 



Status: This project is in the early implementation stage. 
With the August 22, 1996 enactment of the Personal 
Responsibility and Work Opportunity Reconciliation Act 
of 1996, it is anticipated that the Title IV-A component of 
this demonstration will be modified. 

94-089 MAINE-NET: Medicaid and Medicare 
Managed-Care for the Elderly and Physically 
Disabled in Maine 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



ll-C-90437/1 

September 1 994— September 
$ 944,940 
Cooperative Agreement 



997 



HCFA Project 
Officer: 



Careen Wright 

Maine Department of 

Human Services 

Bureau of Medical Services 

State House Station No. 1 1 

Augusta, ME 04333 

Kay Lewandowski 

Division of Aging and Disability 



Description: This project is designed to demonstrate 
integrated models for the financing and delivery of 
managed health care and social services for Medicare and 
Medicaid elderly and physically disabled persons in 
Maine. The project seeks to promote the development of 
regional service delivery networks or health plans, 
particularly in rural areas of the State that would be 
responsible for the management, coordination, and 
integration of services, including multidisciplinary 
approaches to care planning and service delivery. The 
demonstration will provide a comprehensive package of 
primary, acute, and long-term-care institutional and 
noninstitutional services as part of a prepaid-capitated 
health plan for the target populations. The demonstration 
seeks to expand upon nursing home quality indicators 
developed in the Health Care Financing Administration 
sponsored multistate Case-Mix Demonstration Project and 
incorporate HCFA's quality assurance guidelines for 
managed-care plans. In addition, the project will develop 
and use an activity of daily living-based case-mix 
adjustment for long-term-care services in the construction 
of capitation payment rates, using the Resource- 
Utilization-Group III, Version, classification system also 
developed in the multistate demonstration project. For 
services provided in boarding homes and in the 
community, two new case-mix methodologies will be 
developed for use by the demonstration. 

Status: This project is now in its second year. During this 
period, a concept paper describing the State's health care 
environment and the challenges facing the proposed 
demonstration program was drafted. In addition, an 
analysis of the cost and use patterns of State elderly and 



128 



Theme 3: Meeting the Needs of Vulnerable Populations 



disabled Medicare and Medicaid beneficiaries has been 
undertaken, and is expected to be complete by November 
1996. During Year 02, a request for information was 
created and issued, and the responses were reviewed by 
the State. The data from these responses, along with a 
detailed county-by-county environmental analysis 
informed the criteria used for the selection of the two sites 
for the proposed demonstration. The State currently 
anticipates beginning the waiver application process in 
November 1996. 

96-075 Managed-Care System for Disabled and 
Special Needs Children: District of Columbia 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00021/3 

December 1995-November 1998 

Waiver-only Project 

Grant 

Paul Offner 
District of Columbia 
Department of Human Services 
Commission on Health Care Finance 
2100 Martin Luther King, Jr. Ave., SW. 
Suite 302 

Washington, DC 20020 
Phyllis A. Nagy, MHS 
Division of Aging and Disability 



Description: In December 1995, the District of Columbia 
was awarded a section 1115 Medicaid waiver to test the 
efficacy of a managed-care service-delivery system 
designed for disabled and special needs children. 
Participants in the demonstration are children and 
adolescents who are under the age of 22, are eligible for 
Supplemental Security Income (SSI) payments (i.e., 
considered disabled according to SSI guidelines), and are 
subsequently eligible for Medicaid as well. The District of 
Columbia hopes to use the program to eliminate both 
barriers to access and other health care delivery problems 
that children who are disabled and their families 
encounter in the current Medicaid fee-for-service 
program. This managed-care program seeks to improve 
the health status and quality of life for these children, 
while reducing the overall health care costs associated 
with their care. Enrollment in the demonstration is 
voluntary; however, eligible children who do not 
explicitly choose to remain in the current fee-for-service 
system after being informed of the new program are 
assigned to HSCSN after a specified notice period. 
Enrollment cannot be finalized, however, until a health 
needs assessment is completed for each new member. 
Health services under this demonstration are being 
coordinated by Health Services for Children with Special 
Needs, Inc. (HSCSN), a non-profit corporation established 
specifically for the purpose of providing managed care for 
children enrolling in the demonstration. 



Status: The project was implemented in December 1995. 
As of October 1996, approximately 1,500 of the 3,000 
eligible children have chosen to enroll in HSCSN, while 
approximately 500 children/families have chosen to 
remain in the fee-for-service system. 

96-009 Maryland Medicaid Section 1115 
Health Care Reform Demonstration Proposal 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00099/3 

October 1996-April 2002 

Waiver-only Project 

Barbara Shipnuck 

Maryland Department of Health and 

Mental Hygiene 

201 West Preston Street 

Baltimore, MD 21201 

Gina P. Clemons 

Office of State Health Reform 

Demonstrations 



Description: The driving forces behind this statewide 
demonstration are the rapidly rising costs of Medicaid and 
the poor coordination of care in the current program for 
the sickest, most costly beneficiaries. The program has 
been developed on the basis of several guiding principles: 
provide a patient-focused system; build on the strengths of 
the current Maryland health care system; provide 
comprehensive, prevention-orientated systems of care; 
hold managed-care organizations (MCOs) accountable for 
high-quality care; and achieve better value and 
predictability for State expenditures. Maryland intends to 
enroll all waiver eligibles into an MCO or rare and 
expensive case-management system. Mental health 
services will be provided under the demonstration in a 
separate fee-for-service delivery system. 

Status: The program will be phased-in over a 6-month 
period beginning January 1997. 

95-048 Maryland Welfare Reform: 
Family Investment Program 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00066/3 

August 1995-December 1999 

Waiver-only Project 

Alvin C. Collins 
Maryland Department 
of Human Resources 
3 1 1 West Saratoga Street 
Baltimore, MD 21201-3521 
Joan Peterson, Ph.D. 
Office of State Health Reform 
Demonstrations 



Theme 3: Meeting the Needs of Vulnerable Populations 



129 



Description: The original demonstration consisted of two 
components: one that was implemented statewide and the 
other, a pilot, that was implemented in two counties and in 
two district offices in Baltimore City. Statewide, the 
project required unmarried teenage parents to reside with 
a guardian; eliminated increased Aid to Families with 
Dependent Children (AFDC) benefits for additional 
children conceived while the mother is receiving AFDC, 
but provided third-party payment or voucher/vendor 
payment for the difference; and issued AFDC benefits 
14 days after the application date. In the pilot sites, the 
demonstration tested a number of provisions designed to 
encourage work and the transition to self-sufficiency. It 
provided a one-time payment in lieu of AFDC benefits for 
families facing a short-term financial crisis; disregarded 
step-parent income if it was below 100 percent of the 
Federal poverty level (FPL); reduced the grant by 
50 percent of the need standard if income is between 
100 and 150 percent of the FPL; based the grant for 
families with earnings at 85 percent of the difference 
between the need standard and earnings; eliminated Jobs 
Opportunity and Basic Skills (JOBS) training program 
exemptions for having a child under 3 years of age and 
for having a medical disability of more than 12 months, 
unless recipient applies for Supplemental Security 
Income; after 3 months, required able-bodied recipients to 
meet a work requirement that may consist of full-time 
unsubsidized employment, 30 hours of subsidized 
employment, or a total of at least 20 hours of community 
service and employment; and several other AFDC 
provisions. Transitional Medicaid was extended from 
12 to 24 months. For months 13 through 24, this benefit 
would not be made available where the individual had 
access to employer-based health insurance. In August 
1996, substantial amendments to this demonstration were 
approved. Statewide, these amendments consist of new 
provisions and also expand, with some modifications, 
previously approved Family Investment Program pilot 
county provisions to be statewide: impose immediate full- 
family sanctions for fraud and for failure to cooperate 
with JOBS or child support enforcement requirements; 
replace the current $90 and S30-and-one-third disregards 
with a flat 20 percent earned-income deduction; eliminate 
the S50 child support pass-through; reduce the adverse 
notification period to 5 business days; allow case 
managers to set AFDC certification periods up to 1 year 
and require eligibility to be re-established before the end 
of each certification period; provide welfare avoidance 
grants of up to 3 months' benefit amount (up to 
12 months in special circumstances); allow Title IV-A 
child care funds in lieu of AFDC for families diverted 
from cash assistance; and several other provisions. In 
addition, the Health Care Financing Administration has 
permitted the State to provide transitional Medicaid 
benefits to individuals who are under-employed or just 
starting a job and elect to receive Medicaid in lieu of cash 



assistance. At the end of 3 months, such cases are to be 
treated the same as a case ineligible for cash assistance 
due to employment, and are eligible for 12 months of 
transitional Medicaid benefits. 

Status: With the August 22, 1996 enactment of the 
Personal Responsibility and Work Opportunity 
Reconciliation Act of 1996 (PRWORA), it is anticipated 
that the Title IV-A component of this demonstration will 
be modified. In fact, the State has decided to delay 
implementation of the amendments while the impact of 
PRWORA is being analyzed. 

95-069 Massachusetts Welfare Reform, 1995 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00065/1 

November 1 995— November 2005 

Waiver-only Project 

Gerald Whitburn 

Executive Office of Health and 

Social Services 

One Ashburton Place 

Room 1109 

Boston, MA 02108 

Alisa Adamo 

Office of State Health Care Reform 

Demonstrations 



Description: The major components of this demonstration 
are a 2-year time limit on Aid to Families with Dependent 
Children (AFDC) within every 60 months, with 
extensions in certain cases, and a work requirement for 
those on AFDC for more than 60 days. Certain recipients 
are exempt from the time limit and the work requirement 
(e.g., the disabled, pregnant women). Recipients who are 
not exempt will be asked to sign an Employment 
Development Plan. The plan will address such 
requirements as school attendance for children and minor 
parents, immunizations for children, and employment- 
related requirements for adults. Refusal to sign the plan 
will result in the case head being sanctioned. 

One component in the demonstration is the Full 
Employment Program (FEP), under which AFDC and 
cashed-out food stamp benefits will be used to provide a 
wage subsidy. Under this provision, some individuals who 
are not able to find unsubsidized positions will be placed 
in subsidized private-sector jobs. A benefit of the FEP will 
be an Individual Assets Account, into which the employed 
pays S 1 for each participant hour worked. Upon leaving 
the FEP for an unsubsidized job of at least 30 hours per 
week, or because she/he is no longer employed, or after 
12 months of participation in the FEP, whichever is 
sooner, the participant may claim the Individual Assets 
Account. If the money is withdrawn before leaving 
AFDC, it is a countable resource. However, the account is 



Theme 3: Meeting the Needs of Vulnerable Populations 



established as a work incentive and will provide a small 
sum of money to help in the transition from welfare to 
independence. 

Additional incentives are being provided to encourage 
people to work. These include income disregards and 
transitional Medicaid. Medicaid waivers were required in 
order to provide 12 months transitional Medicaid to 
families without regard to income. 

Status: The program began on November 1, 1995. With 
the August 22, 1996 enactment of Personal Responsibility 
and Work Opportunity Reconciliation Act of 1996 
(PRWORA), it is anticipated that the Title IV-A 
component of this demonstration will be modified. 
However, the impact of the PRWORA is being analyzed. 

95-024 MassHealth: Massachusetts Health 
Reform Demonstration 

Project No.: 1 l-W-00030/1 

Period: April 1995-April 2001 

Award: Waiver-only Project 

Principal 

Investigator: Bruce Bullen 

Awardee: State of Massachusetts 

600 Washington Street 

Boston, MA 021 11 
HCFA Project Edward T. Hutton, Ph.D. 
Officer: Office of State Health Reform 

Demonstrations 

Description: The Health Care Financing Administration 
approved waivers for the Massachusetts Medicaid 
demonstration proposal entitled "MassHealth" on 
April 24, 1995. Under the approved demonstration 
Massachusetts would make comprehensive health care 
coverage available to approximately 1.1 million 
individuals, including 700,000 currently eligible for 
coverage under the Massachusetts Medicaid program and 
400,000 who will become newly eligible. The new 
eligibles include 160,000 uninsured poor and low-income 
individuals and families at risk of losing health insurance. 

The Commonwealth estimated that a majority of the 
uninsured under 200 percent of the Federal poverty level 
(FPL) will become insured through MassHealth. The 
other targeted populations under the demonstration 
include low-income short-term unemployed, working 
disabled adults and disabled children, populations limited 
by insurance administration barriers (i.e., pre-existing 
condition exclusions and waiting periods), and small 
businesses and non-group members seeking purchasing 
leverage. 

MassHealth represents a set of strategies to improve 
access to health insurance and to stimulate the offering of 
affordable coverage. The program builds on the 



Commonwealth's existing managed-care program, which 
is made up of health maintenance organizations and a 
Primary Care Clinician Program and existing State-only 
programs for the disabled and short-term unemployed. 
The demonstration will be composed of the six strategies, 
which will be partially financed by redistributing 
disproportionate share hospital payments. The strategies 
streamline eligibility for the current Medicaid program, 
provide health insurance for non-Medicaid-eligible 
disabled and the unemployed, advance existing Medicaid 
managed-care programs, and make employer and 
employee subsidies available for health insurance 
coverage for the working poor. 

Status: The State enacted health reform enabling 
legislation on July 20, 1996, which may require changes 
to the approved demonstration. The State Medicaid 
Agency will have to submit an amendment and protocol 
that reflect the legislation before the demonstration can be 
implemented. 

90-062 Medicaid Analysis Project for States 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-90-0045 
September 1990-March 
$ 5,529,431 
Contract 



1996 



Suzanne Dodds 
MedStat/SysteMetrics, Inc. 
Santa Barbara Corporate Center 
5425 Hollister Avenue, Suite 140 
Santa Barbara, CA 93 1 1 1 
Debbie Lewis 

Bureau of Data Management and 
Strategy 



Description: This contract expands the collection of 
person-level data from the Medicaid Management 
Information Systems (MMIS) maintained by the States. 
Data are being collected from the States that have 
participated in the Medicaid Tape-to-Tape project. Major 
activities are: 

• Assisting in the production and verification of State 
Medicaid Research Files (SMRF) from files. 

• Providing a consistent complementary link between the 
Medicaid Tape-to-Tape project activities and the 
development of SMRFs. 

• Obtaining person-level data on Medicaid enrollment, 
use, payments, and providers from the State MMIS. 

• Developing uniform data file structures to facilitate the 
comparison of Medicaid program statistics among these 
States. 

• Producing streamlined research databases to support 
analysis of policy and program management 
alternatives for Medicaid. 



Theme 3: Meeting the Needs of Vulnerable Populations 



131 



Status: The contract was completed on March 31, 1996. 
Data specifications are available in final format from the 
project officer. 

92-023 Medicaid Capitation Rate Development 

Project No.: 18-C-90 135/3 

Period: February 1992— January 1996 

Funding: $ 473,326 

Award: Cooperative Agreement 

Principal 

Investigator: Gordon Trapnell 

Awardee: Actuarial Research Corporation 

6928 Little River Turnpike, Suite E 

Annandale, VA 22003 
HCFA Project Ronald W. Lambert 
Officer: Division of Delivery Systems and 

Financing 

Description: This project developed a methodology that 
can be replicated by States to set capitation rates for 
Medicaid coordinated care plans. The project was 
conducted in two phases. In the first phase, the quality of 
data from the Health Care Financing Administration's 
(HCFAs) Medicaid Statistical Information System (MSIS) 
was examined for four States to determine whether these 
data are appropriate for capitation rate development. The 
second phase involved the development of actuarial 
methods needed to set the rates. Separate rate cells were 
developed for categories of enrollees that have a large 
impact on overall payment to a plan. The methods for 
database creation and rate setting were documented in a 
manual that the States can use. 

Status: The project has been completed. Fiscal year (FY) 
1990 costs per person year were calculated for each type 
of Medicaid eligible by age group and type of service. 
Geographic factors were also calculated. Adjustment 
factors were used to develop FY 1993 upper payment 
limits from the FY 1990 baseline. Adjustment factors for 
administrative expenses, offsetting interest income, and 
reinsurance were incorporated. Methods for determining 
the actual capitation rates were suggested. A manual was 
produced that can be used by States to set rates. 

92-082 Medicaid Demonstration and Evaluation 
Support Projects: Master Contract: Research Triangle 
Institute (Formerly, Medicaid Demonstration and 
Evaluation Support Projects: Master Contracts) 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



500-92-0033 

September 1992-September 1997 

Contract 

James Lubalin, Ph.D. 

Research Triangle Institute 

P. O. Box 12194 

Research Triangle Park, NC 27709 



HCFA Project Bonnie M. Edington 
Officer: Division of Health Information and 

Outcomes 

Description: This master contract provides for the design, 
development, conduct, and evaluation of Medicaid 
demonstration and evaluation support projects. The intent 
of these demonstration projects is to obtain information in 
a timely manner for program and policy consideration. 

Status: This master contract was awarded in September 
1992. This awardee was able to compete for individual 
delivery orders (DOs) for 36 months. The first DO 
(awarded concurrently with the base contract) is for 
general management, which includes submitting monthly 
reports, meeting with the Federal Government on request, 
and responding to requests for issue papers. The overall 
36-month funding amount of the first DO, 500-92- 
0033DO01, Management Delivery Order, is $52,099. The 
master contract has been given a no-cost extension 
through September 1997. The individual DO projects 
awarded under the master contract are described in detail 
in the following sections of this edition of the Active 
Projects Report. 

Theme 3: Needing the Needs of Vulnerable Populations 

• Evaluation of Medicaid Managed-Care Programs with 
1915(b) Waivers, 500-92-0033DO02. 

• Study of State Health Care Reform Initiatives, 
500-92-0003DO03 

92-084 Medicaid Demonstration and Evaluation 
Support Projects: Master Contract: SysteMetrics/ 
MedStat (Formerly, Medicaid Demonstration and 
Evaluation Support Projects: Master Contracts) 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-92-0035 

September 1992-September 1998 

Contract 

Marilyn Ellwood 

MedStat Group 

104 West Anapamu Street 

Santa Barbara, C A 93101 

Bonnie M. Edington 

Division of Health Information and 

Outcomes 



Description: This master contract provides for the design, 
development, conduct, and evaluation of Medicaid 
demonstration and evaluation support projects. The intent 
of these demonstration projects is to obtain information in 
a timely manner for program and policy consideration. 

Status: This master contract was awarded in 
September 1992. This awardee was able to compete for 
individual delivery orders (DOs) for 36 months. The first 
DO (awarded concurrently with the base contract) is for 



13: 



Theme 3: Meeting the Needs of Vulnerable Populations 



general management, which includes submitting monthly 
reports, meeting with the Federal Government on request, 
and responding to requests for issue papers. The overall 
36-month funding amount for the first DO, 500-92- 
0035DO01, management delivery order, is $41,151. The 
master contract has been given a no-cost extension 
through September 1998. The individual DO projects 
awarded under the master contract are described in detail 
in the following section of this edition of the Active 
Projects Report. 

Theme 3: Meeting the Needs of Vulnerable Populations 

• Community-Supported Living Arrangements Program: 
Process Evaluation, 500-92-0035DO02. 

• State Health Care Reform Monitoring, 
500-92-0035DO03. 

96-007 Medicaid Demonstration Project for 
Los Angeles County 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00076/9 

July 1996-June2000 

Waiver-only Project 

John Rodriguez 

State of California as the Single 

State Agency 

Department of Health Services 

714/744 P Street 

P. O. Box 942732 

Sacramento, CA 94234-7320 

Gina P. Clemons 

Office of State Health Reform 

Demonstrations 



Description: This 5-year, budget-neutral demonstration 
will provide fiscal relief to the County, stabilize the public 
health system, and assist the process of restructuring the 
County's health care delivery system to rely more on 
primary and outpatient care. It will implement the 
agreement reached in September 1995 with State and 
County officials, and is the result of a partnership effort 
by Federal, State, and county governments. 

Status: Federal representatives continue to provide 
technical assistance to the State and county in the efforts 
to restructure the county health care delivery system. 

91-084 Medicaid Extension of Eligibility to Certain 
Low-Income Families Not Otherwise Qualified to 
Receive Medicaid Benefits: Extending Medical 
Coverage to Certain Low-Income Families 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 



ll-C-99657/4 

September 1991-August 1996 

$ 720,774 

Cooperative Agreement 

Rochelle Salsman 



Awardee: 



HCFA Project 
Officer: 



Mandate: 



State of Washington 

Department of Social and Health Studies 

617 Eighth Avenue, SE. 

Olympia, WA 98504-5510 

James P. Hadley 

Office of State Health Reform 

Demonstrations 

Omnibus Budget Reconciliation Act 
of 1990 (Public Law 101-508) 



Description: Section 4745 of the Omnibus Budget 
Reconciliation Act of 1990 mandates a 3-year 
demonstration project to test the effect of eliminating the 
categorical eligibility requirement and raising the 
financial eligibility limits to 150 percent of the Federal 
poverty level (FPL) on low-income individual' access to 
and cost of health care. The Washington project, Health 
Access Spokane (HAS), is a collaborative effort between 
two State agencies, the Department of Social Services' 
Medical Assistance Administration, and the Washington 
Basic Health Plan (BHP). The program covers those who 
are under 65 years of age, are not eligible for Medicaid, 
and have incomes below 200 percent of the FPL. In 
addition to providing coverage to the uninsured, this 
project tests the ability of the State to provide "seamless" 
coverage for individuals and families as they move from 
BHP to demonstration or to Medicaid status. During these 
transitions, coverage will be maintained and providers 
will remain the same, although there are differences in 
benefits available, depending on the program for which 
the individual is eligible. Individuals living in Spokane 
eligible to enroll in HAS are: 

• Current BHP members with family incomes below 
150 percent of the FPL. 

• Individuals who are currently uninsured and have 
incomes below 150 percent of the FPL. 

• Individuals who no longer qualify for Medicaid, but 
whose family income is below 150 percent of the FPL. 
Services are delivered through a health maintenance 
organization (HMO) and a preferred provider 
organization (PPO). Enrollees are given a choice of 
plans. The organizations are paid a negotiated 
capitation rate, based on past experience with BHP 
enrollees and the additional benefits that will be offered 
in the demonstration HMO and PPO. The enrollment 
goal for the project is 2,950 members. Of this total, 

1 ,200 are conversions from BHP. 

Status: HAS began enrollment March 1, 1993. Service 
delivery began April 1, 1993. Although the State was able 
to quickly enroll the 1,200 individuals that were "rolled 
over" from the BHP component, the State was less 
successful in enrolling individuals from the two primary 
populations of interest. Although the demonstration began 
some preliminary work on the employer component, it 
dropped this component during Summer 1993, to focus on 



Theme 3: Meeting the Needs of Vulnerable Populations 



133 



the enrollment of the previously uninsured. The project 
continued providing coverage to enrollees through 
March 31, 1996. Phase-out was completed September 30, 
1996. The evaluation of the demonstration, being 
conducted by Health Economics Research (contract 
number 500-92-0062), is scheduled to be completed 
September 30. 1997. 

91-083 Medicaid Extension of Eligibility to Certain 
Low-Income Families Not Otherwise Qualified to 
Receive Medicaid Benefits: South Carolina Health 
Access Plan (SCHAP) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandate: 



ll-C-99653/4 

September 1991-August 1997 

S 500,000 

Cooperative Agreement 

Bruce Bondo 

South Carolina State Health and Human 

Services Finance Commission 

P. O. Box 8206 

Columbia, SC 29202-820 

James P. Hadley 

Office of State Health Reform 

Demonstrations 

Omnibus Budget Reconciliation Act 
of 1990 (Public Law 101-508) 



Description: Section 4745 of the Omnibus Budget 
Reconciliation Act of 1990 mandates a 3-year 
demonstration project to test the effect of eliminating the 
categorical eligibility requirement and raising the 
financial eligibility limits to 150 percent of the Federal 
poverty level (FPL) on low-income individuals' access to 
and cost of health care. In two South Carolina counties 
(Hoary and Marion), uninsured individuals below 150 
percent of the FPL who are employed by small firms that 
have not offered health insurance coverage to their 
employees within the past 12 months will be offered 
coverage for themselves and their families. To be eligible 
for participation, employers must be located in 1 of the 2 
demonstration counties, employ a minimum of 3 and a 
maximum of 100 employees, and not offer health 
insurance currently within the past 12 months. 
Individuals employed are eligible if they have South 
Carolina residency; have total family incomes under 
150 percent of the FPL; are under 65 years of age; and are 
not currently covered by Medicaid, Medicare, or other 
health insurance programs. All care is delivered through a 
primary-care gatekeeper system. Physicians in the 
demonstration area who meet the credential requirement 
for participation in Medicaid are recruited to participate 
in the demonstration. Each participating physician is paid 
a monthly fee of S2 per enrollee to manage the care of 
each assigned patient. Demonstration recipients are able 



to choose a physician gatekeeper from a list of 
participating physicians for their health care, as well as 
an early, periodic screening, diagnosis, and treatment 
(EPSDT) provider for their children's health care (both 
could be the same person if the selected physician 
gatekeeper is also an EPSDT screener). The primary care 
physician gatekeeper is responsible for managing, 
coordinating, and controlling the member's/family's use 
of health care services through the direct provision of 
comprehensive primary care services (including providing 
for 24-hour, 7-day-a-week access by telephone), 
authorizing specialist visits, and granting prior approval 
of any hospitalizations. Enrollment is projected to be 
approximately 1,300 participants during each year of the 
demonstration. 

Status: The demonstration's delivery of services was 
scheduled to end February 28, 1996. However, the project 
was extended for 1 year and the current schedule calls for 
service delivery to end February 28, 1997, and the final 
project phase-out to end September 30, 1997. 

94-133 Medicaid Managed Care and 
Avoidable Hospitalization 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-90369/3 
April 1995-March 1996 
$ 177,312 
Cooperative Agreement 

Anne Marie Gadomaski, MD, MPH 

Mary Imogene Bassett Hospital 

One Atwell Road 

Cooperstown, NY 13326 

Penelope L. Pine 

Division of Health Information and 

Outcomes 



Description: Since December 1991, the State of Maryland 
has required most categorically eligible Medicaid 
enrollees to participate in the Maryland Access to Care 
(MAC) Program. Under MAC, each Medicaid enrollee 
chooses (or is assigned) a primary medical provider, who 
provides case-management services and acts as a 
gatekeeper for secondary and tertiary care. One objective 
of MAC is to improve access to primary and preventive 
care for the Medicaid population. In this evaluation, the 
awardee will seek to determine the effect of MAC on the 
number of avoidable pediatric hospitalizations. The 
analysis will be performed using hospital claims data 
from the Maryland Medical Assistance Program and the 
Maryland Health Services Cost Review Commission's 
hospital discharge database (HDD). 

Status: The first tasks will be to verify the reliability of 
the HDD diagnosis codes by comparing them to sampled 
medical records and to select specific International 



34 



Theme 3: Meeting the Needs of Vulnerable Populations 



Classification of Diseases, 9th Revision, Clinical 
Modification codes for analysis. Two quarterly reports 
(April 1, 1995-June 30, 1995 and July 1, 1995- 
September 30, 1995) have been received. Six years of 
HDD files (1989-94) have been processed. The final 
report is under review. 

92-056 Medicaid Program Research to Study Medicaid 
Policy Alternatives for the State of New York 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-92-0059 

September 1 992-December 1996 

$ 194,090 

Contract 

Thomas Fanning, Ph.D. 

New York State Department of 

Social Services 

40 North Pearl Street 

Albany, NY 12243-0001 

Penelope L. Pine 

Division of Health Information and 

Outcomes 



Description: The purposes of this contract are to provide 
the Health Care Financing Administration (HCFA) with 
greater capability to conduct Medicaid program research 
and to study Medicaid policy alternatives of the State of 
New York. Primary goals are to: 

• Obtain person-level Medicaid Management Information 
Systems data from the State. 

• Produce research data sets for analysis of Medicaid 
costs and service utilization. 

• Conduct policy-oriented research studies derived from 
knowledge of the data, program characteristics, and 
policy issues that exist in the New York Department of 
Social Services. 

• Provide support to HCFA staff who will conduct 
policy-related studies using New York Medicaid 
research data sets. 

Status: New York Medicaid enrollment and claims files 
for Federal fiscal years 1990, 1991, and 1992 have been 
received. The studies using the New York data are 
Physician Participation in the Medicaid Program, 
Preferred Physician and Children Program, Designated 
Inpatient Hospital Centers for Persons with Acquired 
Immunodeficiency Syndrome, and Pregnant Women Who 
Are Substance Abusers. 

88-016 Medical Assistance Facility 
Demonstration Project 



Award: 
Principal 
Investigator: 
Awardee: 



HCFA Project 
Officer: 



Mandates: 



Project No.: 

Period: 

Funding: 



95-C-99292/8 

June 1988-July 1997 

$ 140,939 



Cooperative Agreement 

Keith McCarty 
Montana Hospital Research 
and Education Foundation 
P.O. Box 5119 
Helena, MT 59604 
Siddhartha Mazumdar, Ph.D. 
Division of Delivery Systems and 
Financing 

Section 4008(I)(1) of the Omnibus 
Budget Reconciliation Act of 1990 
(Public Law 101-508, amended by 
Section 13507 of the Omnibus Budget 
Reconciliation Act of 1993, 
Public Law 103-66) 



Description: The Montana Hospital Research and 
Education Foundation (MHREF) is conducting a 
demonstration of the utility and desirability of medical 
assistance facilities (MAFs), limited-service hospital 
models located in remote, rural frontier areas. The MAF 
is a new category of licensure in Montana for health care 
facilities providing emergency, outpatient, and low- 
intensity acute-care services to short-term inpatients. 
MAFs are intended to maintain accessibility to basic acute 
and emergency-care services and provide limited inpatient 
care for no longer than 96 hours. These facilities are 
located in counties with fewer than six residents per 
square mile or in areas more than 35 miles from the 
nearest hospital. MAFs maintain agreements with larger 
full-service hospitals and other providers to ensure the 
availability of a full network of services. In enacting 
section 4008(I)(1) of Public Law 101-508, Congress 
provided the authority to implement the demonstration. 
Section 13507 of the Omnibus Budget Reconciliation Act 
of 1993 amends this section of the law and extends the 
demonstration through July 1997. This project consists of 
two phases. 

Status: The MAF demonstration is the first time that 
limited-service hospitals have received Health Care 
Financing Administration (HCFA) certification to be 
reimbursed for the provision of inpatient services to 
Medicare beneficiaries. The project has served as a 
prototype in the development of the Essential Access 
Community Hospital program. HCFA and MHREF have 
worked to develop the MAF concept by defining service, 
staffing, and equipment capabilities at each of the 
demonstration sites. In addition, use and cost projections 
have been prepared to estimate the financial impact of the 
project on the facilities and on the Medicare program. 
HCFA and MHREF have developed conditions of 
participation and certification requirements, quality 
assurance and use review procedures, and payment 
systems for MAFs. MAFs are reimbursed for the provision 



Theme 3: Meeting the Needs of Vulnerable Populations 



135 



of all services on a reasonable-cost basis by the Medicare 
and Medicaid programs (Blue Cross and Blue Shield of 
Montana also participates in the demonstration by 
reimbursing MAFs on a reasonable-cost basis.) Ten 
MAFs are operating currently in Montana. 

93-064 Medicare Beneficiaries Receiving 
Chronic Renal Dialysis Not Identified as 
Having End Stage Renal Disease 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandate: 



HCFA-93-0979 
August 1993-May 1994 
$24,813 
Contract 

Dennis Cotter 

The Medical Technology and Practice 

Patterns Institute 

2121 Wisconsin Avenue, NW. 

Suite 230 

Washington, DC 20007 

Joel W. Greer, Ph.D. 

Division of Health Information and 

Outcomes 

Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 



Description: The final analyses have been completed and 
the final report is being prepared. The Medical 
Technology and Practice Patterns Institute (MTPPI) has 
characterized Medicare beneficiaries who submit bills 
indicating that they receive chronic renal dialysis, but 
who are not identified as having end stage renal disease 
(ESRD). MTPPI will estimate the impact of these persons 
on ESRD program enrollment, incidence, demographic 
characteristics, and costs. 

Status: The final report was received in August 1996 and 
is under review. Significant delays were incurred waiting 
for the data necessary to estimate patient counts and costs. 

89-032 Medicare Catastrophic Coverage Act (MCCA) 
Evaluation: Beneficiary and Program Impact 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-89-0063 

September 1989-September 1995 

$ 2,846,906 

Contract 

David Kidder, Ph.D. 
Abt Associates, Inc. 
55 Wheeler Street 
Cambridge, MA 02138 
Feather Ann Davis, Ph.D. 
Division of Aging and Disability 



Description: MCCA of 1988 expanded and simplified 
Medicare hospital coverage effective January 1989, only 



to be repealed, effective January 1990. The legislation 
reduced Medicare beneficiary liability to one hospital 
deductible per year, eliminated the concept of "spell of 
illness," and eliminated the coinsurance calculations 
necessary under the original Medicare program. The 
legislation made the Part A extended care benefit more 
generous by increasing the day limit on skilled nursing 
facility care from 100 to 150 days per year, and 
eliminated the prior 3-day hospital stay. The coinsurance 
requirements were revised, and the rate was lowered to 
20 percent of the daily cost of nursing home care instead 
of being linked to the average cost of a day of hospital 
care. Also, the coinsurance was to apply only to the first 
8 days of the stay, instead of applying to the 21st through 
100th day. These changes meant that more beneficiaries 
would qualify for coverage and that longer stays would be 
covered. The skilled nursing facility changes went into 
effect in January 1989 and were rescinded, effective 
January 1990. Changes to the Medicare hospice benefit, 
implemented in January 1 990 and rescinded in 
January 1990, eliminated the 210-day lifetime limit on 
hospice benefits, but retained a cost limit. None of the 
other Medicare benefits (Part A or Part B or Drug) of 
MCCA were implemented, having been scheduled for 
implementation after the date that the provisions were 
repealed. The Medicaid provisions of the legislation were 
left intact, including the payment of Part B premiums, 
deductibles and copayments for qualified (poor) Medicare 
beneficiaries, and mandatory Medicaid coverage for 
pregnant women and their infants with income of up to 
100 percent of the Federal poverty level. (The coverage 
was phased in — 75 percent by July 1989 and 100 percent 
by July 1990). 

The evaluation contract comprised a series of research 
projects related to the analysis of Medicare benefit 
changes and Medicaid beneficiary expansions introduced 
by the Medicare Catastrophic Coverage Act (MCCA) of 
1988. The analyses focused on the Medicare benefit 
changes in skilled nursing care and hospice care. The 
analyses also addressed the MCCA-introduced payment of 
Part A and Part B premiums, and the deductibles and 
copayments for low-income qualified Medicare 
beneficiaries by State Medicaid programs. Data on use in 
a private nursing home chain were studied, and nursing 
home episodes for Medicare beneficiaries are identified 
through a linkage of Part A and Part B bills. Post-hospital 
use was studied through two tracer conditions-stroke and 
hip fracture. The Medicaid analyses primarily focused on 
the effects of the expansions for pregnant women and 
their infants. Analyses of birth and death records were 
conducted on national vital statistics data; Missouri birth 
and infant death data were linked with Medicaid 
eligibility and utilization data and analyzed for changes in 
Medicaid enrollment of pregnant women and the birth 
outcomes of their infants. Analysis of a year of infant 
health care utilization includes data from birth certificates 



IV) 



Theme 3: Meeting the Needs of Vulnerable Populations 



and mothers' Medicaid eligibility. A trend analysis of 
Massachusetts hospital discharge data focuses on shifts in 
Medicaid use, lengths of stay, severity of birth outcomes, 
and neonatal intensive care unit use before and after the 
MCCA legislation. 

Status: The following final reports summarize the MCCA 
impact on maternal and child health programs and 
beneficiaries: 

• Laliberte, L., Mor, V., Berg, K., Banaszak-Holl, J., 
Calore, K., Intrator, O., and Hiris, J., "Medicare 
Catastrophic Coverage Act Evaluation: The Impact of 
the Medicare Catastrophic Coverage Act on the Long- 
Term Care System," June 1995. 

• Coulam, R.F., Cole, N., Irvin, C, Kidder, D., and 
Schmitz, R.J.: "Evaluation of the Medicare 
Catastrophic Care Act: Final Report," 
December 19, 1995. 

89-028 Medicare Catastrophic Coverage Act 
Evaluation: Impact on Industry 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-89-0064 

September 1989-September 1994 

$ 993,199 

Contract 

Marilyn Moon, Ph.D. 
Urban Institute 
2100 M Street, NW. 
Washington, DC 20037 
Feather Ann Davis, Ph.D. 
Division of Aging and Disability 



Description: A series of analyses of the effects of the 
Medicare Catastrophic Coverage Act (MCCA) of 1988 on 
hospitals, nursing homes, and home health agencies. Two 
final reports summarize the work of the contract: 

• Moon, M., Dubay, L., Kenney, G., Liu, K., Marsteller, 
J., and Norton, S.: "Medicare Catastrophic Coverage 
Act Evaluation: Preliminary Analysis of Impact on 
Industry: Final Report." September 1995. 

• Liu, K., Kenney, G., Wissoker, D., and Marsteller, J.: 
"The Effects of the Medicare Catastrophic Coverage 
Act and Administrative Changes on Medicare SNF 
Participation and Utilization: 1987-1991." 
Washington, D.C., June 1995. 

Important findings are: 

Nursing facilities — The Health Care Financing 
Administration's claims data and nursing facility 
certification data were used in the study of changes in 
facility certification from non-Medicare SNF or 
intermediate care facility (ICF) to Medicare SNFs and 
changes in Medicare-certified beds, to determine how 
nursing homes increased or decreased their capacity to 



provide Medicare SNF services. Analysis findings are 
consistent with the national program statistics, both 
indicating large increases in the utilization of Medicare 
SNF days between 1987 and 1989, and a decline in 
covered days between 1989 and 1991. The magnitude of 
the change between 1987 and 1989 strongly suggests that 
the MCCA, along with the clarification of coverage 
guidelines, had an impact on the SNF benefit during this 
period. Multivariate analyses demonstrated differential 
responses in the provision of SNF services by provider 
characteristics, i.e., proprietary and larger nursing homes, 
rather than government-owned or smaller nursing homes, 
were the most responsive to the MCCA and coverage 
guidelines. Freestanding SNFs had greater increases in 
covered days per bed, admissions per bed and length of 
stay between 1987 and 1989 than hospital-based SNFs. 
Some of the differences in growth were probably 
attributable to the transfer of Medicaid residents of 
freestanding SNFs to Medicare payment status; hospital- 
based facilities generally not providing long-term nursing 
care and, hence, having fewer patients to convert to 
Medicare SNF. The increase in Medicare patients after 
the implementation of these policy changes was offset by 
a disproportionate decrease in private-pay patients, 
indicating that the policies increased the role of public 
financing for nursing home care. Nursing homes in states 
that employ a case-mix adjustment in setting their 
Medicaid nursing home payment were generally more 
likely than homes in other States to begin participating in 
Medicare and to have had greater growth in Medicare 
utilization. Medicare-certified service provision expanded 
greatly even with the repeal of the MCCA, and more 
nursing beds became certified for Medicare over the study 
period. The expansions in access are likely the 
consequence of: 

• The coverage clarifications that may have served to 
make nursing homes more willing to serve Medicare 
patients because of greater certainty regarding Medicare 
coverage policy. 

• MCCA may have given nursing homes greater 
familiarity with Medicare. 

• Staffing data suggest that OBRA 1987 led to increases 
in staff levels, making it easier for more nursing homes 
to serve Medicare patients. 

Although Medicaid still dominates the financing in the 
nursing home industry, the policy and industry changes 
have pushed Medicare more to the forefront of financing 
nursing home care. 

Home health — Analyses of the changing home health 
market in response to MCCA and other regulatory 
changes suggest a complicated set of relationships and 
causal factors. The descriptive analysis suggested an 
inverse relationship between SNF use and home health 
use. Similarly, the simultaneous regression results did not 
show a substantial number of Medicare enrollees shifting 



Theme 3: Meeting the Needs of Vulnerable Populations 



137 



away from the Medicare home health benefit in favor of 
the Medicare SNF benefit as a result of MCCA. Although 
analyses found no offset between nursing home and home 
health utilization, they did show that larger increases in 
home health occurred in areas with higher Medicare 
discharges in diagnosis-related groups with high use of 
postacute care. Larger increases in home health use also 
occurred in areas with high proportions of dually eligible 
enrollees. Findings that much of the growth in home 
health care was associated with less skilled agencies 
suggest that the service needs of new Medicare 
beneficiaries are more likely to involve personal care 
rather than specialized care such as physical therapy or 
medical services. Users of rehabilitation services seem to 
be similar to those using home health services across many 
dimensions; SNF users, in contrast, are older and more 
likely to be female and/or unmarried. The ratio of home 
health agencies per enrollee and nursing home bed 
moratoria had significant effects on use of health services. 
Home health agencies substantially expanded the scope of 
services offered between 1983 and 1989, with urban areas 
offering more comprehensive services than rural settings. 

Hospitals — Analyses concluded that MCCA decreased 
beneficiary out-of-pocket expenditures. Even though 
overall bad debt in hospitals increased, the bad debt for 
hospitals with the largest maternity load decreased, 
reflecting the impact of MCCA's Medicaid eligibility 
expansion for poor/pregnant women and their infants. 

92-076 Medicare Institutional/Facility-Based 
Services Demonstration Projects: Master Contract: 
Mathematica Policy Research, Inc. (Formerly, Medicare 
Institutional/Facility-Based Services Demonstration 
Projects: Master Contracts) 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



500-92-0047 

September 1 992-September 1997 

Contract 



Judith Wooldridge 

Mathematica Policy Research, Inc. 

P. O. Box 2393 

Princeton, NJ 08543-2393 
HCFA Project Victor G. McVicker 
Officer: Division of Delivery Systems and 

Financing 
Description: This master contract provides for the design, 
development, conduct, and evaluation of Medicare 
institutional/facility-based services demonstration 
projects. The intent of these demonstration projects is to 
obtain information in a timely manner for program and 
policy consideration. 

Status: This master contract was awarded in September 
1992. This awardee is able to compete for individual 
delivery orders (DOs) for 36 months. The first DO 



(awarded concurrently with the base contract) is for 
general management, which includes submitting monthly 
reports, meeting with the Federal Government on request, 
and responding to requests for issue papers. The overall 
36-month funding amount for the first DO, 500-92- 
0047DO01, Management Delivery Order, is $38,706. 
This master contract ended on September 30, 1995. The 
individual DO projects awarded under the master contract 
are described in detail in the following section of this 
edition of the Active Projects Report. 

Theme 3: Monitoring and Evaluating Health Systems 
Performance: Access, Quality, Program Efficiency and 
Costs 

• Evaluation of the Iowa Implementation of Ambulatory 
Patient Groups (APGs), 500-92-0047DO02. 

• Evaluation of the Rural Health Clinics, 
500-92-0047DO03. 

96-073 Mental Health Service Utilization by 
the Elderly in Tennessee: The Effect of Race, 
Social Class, and Comorbidity 

Project No.: 20-C-90705/4-01 

Period: September 1 996-September 1998 

Funding: $ 197,852 

Award: Cooperative Agreement 

Principal 

Investigator: Baqar Husaini, Ph.D. 

Awardee: Tennessee State University 

3500 John Merritt Boulevard 
Nashville, TN 37209-1561 

HCFA Project Richard Bragg 

Officer: Division of Aging and Disability 

Description: This 2-year collaborative project will 
examine the effects of race, socioeconomic status and 
comorbidity on utilization of mental health services by the 
elderly of Tennessee during 1989-92. This period for the 
analysis of Medicare data is chosen because it corresponds 
to the same time when two large multi-year surveys on 
randomly selected African American and white elderly of 
Nashville were conducted. The study would examine the 
role of social class, ethnicity, comorbidity, diagnosis, type 
of services and mortality among the mentally afflicted. 
Costs also will be included in the analysis. The specific 
objectives of the analysis are to determine the effect of 
race, social economic status (SES) (using education and 
income), and comorbidity on mental health service 
utilization including hospital and outpatient in Tennessee. 
It would determine the racial patterns of mental health 
service use by clinical diagnosis, examine the effect of 
comorbidities and SES on patterns of service utilization 
within each racial group, and determine the effect of 
comorbidity and SES on the cost of hospitalization 
by race. 



Theme 3: Meeting the Needs of Vulnerable Populations 



Status: This project is in its early design phase. 

95-029 Minnesota Prepaid Medical Assistance 
Project Plus (PMAP+) 



Project No: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00039/5 

July 1995-June 1998 

Waiver-only Project 

Patricia MacTaggart 

Minnesota Department of 

Human Services 

444 Lafayette Road 

St. Paul, MN 55101 

Bruce R. Johnson 

Office of State Health Reform 

Demonstration 



Description: The Minnesota Prepaid Medical Assistance 
Project Plus (PMAP+) amended the original Minnesota 
Medicaid Demonstration by expanding the project in both 
size and scope. The PMAP demonstration enrolled all Aid 
to Families with Dependent Children (AFDC) eligibles, 
needy children, and pregnant women in eight Minnesota 
counties into prepaid managed-care organizations. 
PMAP+ expanded prepaid managed care to nine 
additional counties and is expected to eventually be a 
statewide program. In addition, Medicaid eligibility was 
expanded on a statewide basis to include children and 
pregnant women up to 275 precent of the Federal poverty 
level who were previously covered under the State's 
MinnesotaCare program. PMAP+ will also implement a 
prepaid dental program and children's mental 
collaboratives, and will enroll persons with disabilities in 
Itasca County in PMAP+. 

These requested changes to the original Medicaid 
demonstration are part of a series of health care reform 
measures enacted by the State to improve health care 
quality and create a seamless system of care for its 
population. The MinnesotaCare Acts of 1992, 1993, and 
1994 call for specific changes in the health care delivery 
and financing system, and Phase I involves the 
integration of low-income and uninsured programs and 
the expansion of managed care. Under the PMAP+ 
demonstration the State is proceeding with Phase I and is 
working with the Health Care Financing Administration 
(HCFA) to develop Phase II of the project, which would 
further streamline all publicly funded health care 
programs in the State. 

Status: HCFA's approval of PMAP+ allows the State to 
expand into the counties of Aitken, Cook, Koochinching, 
Benton, Sherburne, Stearns, St. Louis, Lake, and Carlton. 



There are currently approximately 160,000 enrollees in 
PMAP+ managed-care organizations. In addition, the 
State's eligibility expansion has made approximately 
52,000 MinnesotaCare children and pregnant women 
Medicaid-eligible. The State has formed County 
Development Teams for the central and northeast areas of 
the State to assure a smooth transition to managed care in 
each of these as well as additional counties slated for 
expansion now or in the future. The State has begun 
preliminary planning for the children's mental health 
collaboratives and has awarded planning grants to 
20 collaboratives serving 32 counties. Phase II of 
Minnesota's Health Care Reform is expected to be 
submitted in the coming months. 

96-042 Minnesota's Work First Demonstration 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



11-W-00 103/5 

October 1996-October 2001 

Waiver-only Project 

Maria Gomez 

Minnesota Department of 

Human Services 

444 Lafayette Road 

St. Paul, MN 55155 

Alisa Adamo 

Office of State Health Reform 

Demonstrations 



Description: Work First project is implemented in Clay 
and Carver counties. It consists of a number of welfare 
reform strategies. Medicaid waivers were needed so that 
people could receive the transition benefit regardless of 
whether they had been on AFDC for 3 out of the previous 
6 months. 

Status: The project was implemented on October 1996. 
With the August 22, 1996 enactment of the Personal 
Responsibility and Work Opportunity Reconciliation Act 
of 1996 (PRWORA), it is anticipated that the Title IV-A 
component of this demonstration will be modified. 
However, the impact of the PRWORA is being analyzed. 

95-049 Montana Welfare Reform: Families Achieving 
Independence in Montana (FAIM) 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



ll-W-00040/8 

April 1995-January 2004 

Waiver-only Project 

Peter S. Blouke, Ph.D. 

Montana Department of Public Health 

and Human Services 

P.O.Box 4210 

Helena, MT 59604-4210 



Theme 3: Meeting the Needs of Vulnerable Populations 



139 



HCFA Project 

Officer: 



Joan Peterson. Ph.D. 

Office of State Health Reform 

Demonstrations 



Description: Statewide, this demonstration establishes: 

• A Job Supplement Program consisting of a set of Aid 
to Families with Dependent Children (AFDC)-related 
benefits to assist individuals at risk of becoming 
dependent upon welfare. 

• AFDC Pathways Program, in which all applicants must 
enter into a family investment agreement requiring 
parents to secure child support, obtain early, periodic 
screening, diagnosis and treatment (EPSDT) services 
and immunizations for their children, and participate in 
the State's Jobs Opportunity and Basic Skills program 
and limiting adults' benefits to a maximum of 24 
months for single parents and 18 months for two-parent 
families. 

• A community services program requiring 20 hours per 
week for individuals who reach the AFDC time limit 
but have not achieved self-sufficiency. 

Montana has expanded Aid to Families with Dependent 
Children-Unemployed Parent eligibility and increased the 
resource and automobile equity limits for AFDC and Food 
Stamp recipients. The State also increased the dependent 
care disregard, as well as disregards of energy assistance 
payments, earned income of dependent children in school, 
gifts of money for special occasions, and child support 
payments made to non-household members for AFDC and 
Food Stamp purposes. Under its demonstration, 
enrollment of adult participants in a health maintenance 
organization (HMO) is mandated where geographically 
available. In areas where an HMO is not available, 
Montana offers basic Medicaid coverage through Passport 
to Health, Montana's primary-care case-management 
program. 

Status: This project was implemented in February 1996. 
With the August 22, 1996 enactment of the Personal 
Responsibility and Work Opportunity Reconciliation Act 
of 1996 (PRWORA), it is anticipated that the Title IV-A 
component of this demonstration will be modified. 
However, the impact of the PRWORA is being analyzed. 

94-073 Multistate Analysis of Utilization, 
Expenditures, and Access to Care for Persons with 
Acquired Immunodeficiency Syndrome 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Auardce: 



500-92-0022DO04 

September 1 994-December 1996 

$490,1 14 

Delivery Order in Master Contract 

Craig Thornton, Ph.D. 
University of Minnesota 



HCFA Project Lawrence E. Kucken and 
Officers: Michael Kendix, Ph.D. 

Division of Health Information and 

Outcomes 

Description: The objective of the project is to conduct a 
study of persons with acquired immunodeficiency 
syndrome (AIDS) and human immunodeficiency virus 
(HlV)-related diseases. In particular, the project will 
conduct a statistical investigation and will examine trends 
in enrollment, service use, and expenditure patterns of 
Medicare, and California Medicaid patients. It will 
compare these programs and assess differences in access 
to care. The project will provide more expansive and 
current data on use and expenditures related to AIDS and 
HIV health services. 

Status: Medicare analysis files for the period 1991 
through 1993 and California Medicaid files for the period 
1991 through 1992 have been completed. Descriptive 
analyses are currently under review. 

93-048 National Health Interview Survey Disability 
Supplement: 1994-95 (Formerly, A 1994/1995 National 
Health Interview Survey Disability Supplement) 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



HCFA-IA-9362 
June 1993-June 1994 
Interagency Agreement 

Owen Thornberry 
Centers for Disease Control 
National Center for Health Statistics 
6325 Belcrest Road, Room 850 
Hyattsville, MD 20782 
Elizabeth Mauser, Ph.D. 
Division of Aging and Disability 



Description: The Health Care Financing Administration 
(HCFA) transferred funds to the National Center for 
Health Statistics to support the implementation of the 
1994/1995 disability survey as a supplement to the 
National Health Interview Survey. Although HCFA 
provides extensive support for the disabled through the 
Medicare and Medicaid programs, very little is known 
about this population. The National Health Interview 
Survey Disability Supplement (NHISDS) will be the first 
survey on the disabled in 15 years. The NHISDS will be 
conducted during calendar years 1994 and 1995, with 
approximately 250,000 people of the 96,000 sampled 
households. The survey will consist of two phases: 

• Phase I will screen the relevant populations and will 
collect basic descriptive information. 

• Phase II will obtain information on all household 
members who experience limitations caused by a health 
condition. 



140 



Theme 3: Meeting the Needs of Vulnerable Populations 



Data from Phase I will be used to make estimates of the 
prevalence of disability and to determine eligibility for 
Phase II questionnaires. In Phase II, separate 
questionnaires will be given to adult and child 
respondents. This survey will be the first source of 
information to determine the size, characteristics, service 
use, and out-of-pocket costs for individuals with mental 
retardation and related conditions. The survey of children 
will provide information on the number, characteristics, 
severity, and effects on families of children with 
disabilities. This survey will collect information on 
income and assets, along with basic disability 
information, to better understand the characteristics of 
actual and potential Supplemental Security Income 
recipients. The information gathered from the NHISDS 
will be crucial for addressing a broad number of HCFA 
policy concerns affecting persons with disabilities. 

Status: Questionnaires for the disability supplement have 
been revised. Phase I interviews began in January 1994 
and Phase II adult and children interviews began during 
Summer 1994. The first wave of data from Phase I is 
available. 

94-114 National Minority Historically Black Colleges 
and Universities Health Education Initiative 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



HCFA-IA-4105 

September 1 994-September 1996 

$ 200,000 

Interagency Agreement 

Dorothy G. Moore 

National Association for Equal 

Opportunity in Higher Education 

Black Higher Education Center 

Lovejoy Building 

400 12th Street, NE. 

Washington, DC 20002 

Samuel L. Brown 

Division of Aging and Disability 



Description: The purpose of this interagency agreement is 
for the Health Care Financing Administration (HCFA) to 
provide financial support to the Centers for Disease 
Control (CDC) in support of an existing CDC cooperative 
agreement with the National Association for Equal 
Opportunity (NAFEO) in Higher Education. This 
endeavor includes 1 17 historically black colleges and 
universities (HBCU) participating in the implementation 
of an human immunodeficiency virus (HIV)/acquired 
immunodeficiency syndrome (AIDS) education program. 
This effort will focus on implementation of a model 
program to provide HIV/AIDS education, prevention, and 
information on eligibility criteria for the Medicaid 
program for students and faculty of the 117 HBCUs. The 



objective is to integrate prevention activities into 
curricular and noncurricular programs. In addition, the 
HBCUs shall, in conjunction with NAFEO, develop a 
student pamphlet on State-level Medicaid eligibility 
criteria and coverage policy for minority persons with 
HIV/AIDS. This pamphlet explains the criteria for 
defining HIV/AIDS disability for purposes of establishing 
eligibility for participation in the Medicaid program for 
each HBCU's home State and for identifying the State 
agency that is responsible for making disability 
determinations. The pamphlet also should explain the 
mandatory and optional services available to Medicaid 
eligible minority persons with AIDS. A final report 
prepared by NAFEO will synthesize and integrate the 
results of the Medicaid eligibility criteria and coverage 
policies of each State for every participating HBCU. This 
report shall include an issue paper on the topic of health 
systems reform as it might affect Medicaid eligibility for 
persons with AIDS. Also included will be clarification 
and specification of the major issues or questions 
regarding health care system reform, financing, delivery, 
and quality of care among minority persons with AIDS; a 
review of the published literature on the subject; a 
description of any additional barriers to health care 
services faced by black persons or other minority people 
with AIDS; and the development of alternative courses of 
action in the context of the objective of State-level health 
care system reform and an assessment of the feasibility for 
implementating the proposed alternatives. 

Status: In Spring 1995, a panel session on HIV/AIDS/ 
STD prevention was held in Washington, D.C., at 
NAFEO 's annual conference for HBCU members. This 
panel featured several speakers from HCFA. The grantee 
continues to collaborate with participating HBCUs to 
develop and implement HIV/AIDS/STD awareness and 
education programs. A report on this project was 
submitted in June 1996. 

94-1 13 National Recurring Data Set Project: 
Ongoing National State-by-State Data Collection and 
Policy/Impact Analysis on Residential Services for 
Persons with Developmental Disabilities 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA-IA-9485 

October 1 996-September 1997 

$ 35,000 

Interagency Agreement 

Charlie Lakin, Ph.D. 

University of Minnesota 
Institute of Community Integration 
150 Pillsbury Drive, SE. 
Minneapolis, MN 55455 



Theme 3: Meeting the Needs of Vulnerable Populations 



141 



HCFA Project Samuel L. Brown 

Officer: Division of Aging and Disability 

Description: This interagency agreement will support 
secondary data analyses and the production of a report that 
describes and updates the status of persons with mental 
retardation and related conditions (MR/RC) in institutional 
care facilities for the mentally retarded (ICF-MRs), 
Medicaid waiver programs, and nursing homes funded 
under the Medicaid program to assist in the evaluation of 
Medicaid services for persons with MR/RCs and to point 
out areas in need of reform. The report will include: 

• Background description of the key Medicaid programs 
of interest. 

• State-by-State and national statistics on ICF-MRs, 
Medicaid home and community-based services, and 
nursing home use. 

• Description of the characteristics of ICF-MRs and their 
residents, with comparative statistics for noncertified 
facilities. 

Status: The University of Minnesota continues to collect 
data to produce its annual report on the status of the 
Medicaid programs that serve the developmentally 
disabled. 

95-062 Nebraska Welfare Reform 
Demonstration Project 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-0055/7 

July 1995-July2002 

Waiver-only Project 

Dan Cillessen 

Nebraska Department of Social Services 

P. O. Box 95026 

Lincoln, NE 68509-5026 

Maria Boulmetis 

Office of State Health Reform 

Demonstrations 



Description: Statewide waivers permit Nebraska to give 
no increase in cash benefits for a child born on welfare; 
increase resource limits; impose cash penalties when 
children do not attend school regularly; determine the Aid 
to Families with Dependent Children (AFDC) eligibility 
of minor parents living with adult parents by counting 
parental income in excess of 300 percent of the Federal 
poverty guideline; limit employable adults to a maximum 
of 24 months of AFDC and Medicaid in any 48-month 
period, and require employable adults to participate in 
employment-related activities, with more stringent 
sanctions for non-cooperation. In this time-limited 
program, cases will receive cash in lieu of Food Stamps; 



two-parent families will have the same eligibility 
requirements as single-parent families; adults will choose 
to receive either the current AFDC cash grant and earnings 
disregard or a lower AFDC cash grant and higher earnings 
disregard; and cases who lose AFDC eligibility due to 
earnings will receive 24-month child care and Medicaid 
transition benefits. The Medicaid transition benefit will 
involve quarterly income reporting, with the case losing 
eligibility when income exceeds 185 percent of the 
Federal poverty guideline, and the State may also impose 
cost sharing in months 7-24 of the transition benefit. 

Status: The State continues to implement the 
demonstration. With the August 22, 1996 enactment of 
the Personal Responsibility and Work Opportunity 
Reconciliation Act of 1996 (PRWORA), it is anticipated 
that the Title IV-A component of this demonstration will 
be modified. However, the impact of the PRWORA is 
being analyzed. 

96-047 New Hampshire Employment Program and 
Family Assistance Program 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00083/1 
July 1996-July 2001 
Waiver-only Project 

Terry L. Morton 

Department of Health and 

Human Services 

6 Hazen Drive 

Concord, NH 03301-6505 

Maria Boulmetis 

Office of State Health Reform 

Demonstrations 



Description: The major provisions of the demonstration 
include increasing the requirements on recipients to seek 
and to obtain work; allowing the recipients to keep more 
of their earnings and have more exempt resources; 
streamline eligibility for both Aid to Families with 
Dependent Children (AFDC) and AFDC-related Medicaid 
individuals to reflect the provisions of the demonstration, 
and expand Medicaid eligibility by allowing individuals 
to receive transitional Medicaid benefits even though they 
did not receive AFDC in 3 out of the previous 6 months. 

Status: The State continues to implement the 
demonstration. With the August 22, 1996 enactment of 
the Personal Responsibility and Work Opportunity 
Reconciliation Act of 1996 (PRWORA), it is anticipated 
that the Title IV-A component of this demonstration will 
be modified. However, the impact of the PRWORA is 
being analyzed. 



142 



Theme 3: Meeting the Needs of Vulnerable Populations 



96-048 New Hope Project 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandates: 



ll-W-00098-5 

January 1995-December 1999 

$1.1 million 

Provider Agreement 

Sharon F. Schulz 

New Hope Project, Inc. 

637 North 35th Street 

Milwaukee, WI 53208 

Maria Boulmetis 

Office of State Health Reform 

Demonstrations 

Public Laws 103-432 and 103-333 



92-041 New Jersey Welfare Reform: 
Family Development Program 



Description: New Hope Project, Inc. (New Hope) is a 
private non-profit corporation that offers employment, 
wage supplements, child care, health care, counseling and 
training for job retention or advancement to Aid to 
Families with Dependent Children (AFDC) recipients, the 
working poor, and the unemployed not eligible for AFDC 
for a period of 3 years. The demonstration project is 
targeted to inner urban areas of Milwaukee, Wisconsin. 
The objectives of the demonstration are to measure: 

• The responsiveness of people to the program and the 
economic and non-economic impact of their 
participation. 

• The effectiveness of the program's implementation and 
the potential for replication on a larger scale. 

• Tthe costs and the benefits of the program. 

The expectation is that higher rates of employment and 
earnings, and a reduced need for public assistance, will be 
found among New Hope participants. 

The amount payable to New Hope would be equal to the 
program savings for the demonstration project with 
respect to Title IV-A (AFDC) and Title XIX (Medicaid). 
Program savings are expected to result from reduced Title 
XIX and Title IV-A caseloads. The Title XIX 
demonstration savings will be used to subsidize health 
insurance premiums paid by demonstration participants 
enrolled in either of the two health maintenance 
organizations contracted by New Hope. 

Status: New Hope continues to implement the 
demonstration. The impact of the Personal Responsibility 
and Work Opportunity Reconciliation Act of 1996 
resulted in the reduction of Title IV-A funding by 
allowing IV-A savings to be recognized only through 
September 30, 1996. However, the project will still 
continue to recognize Title XIX savings. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00016/2 

July 1992-September 1997 

Waiver-only Project 

William Waldman 

New Jersey Department of 

Human Services, CN700 

Trenton, NJ 08625-0700 

Alisa Adamo 

Office of State Health Reform 

Demonstrations 



Description: This demonstration has waivers from the 
Health Care Financing Administration and the 
Administration for Children and Families to: 

• Require that recipients of Aid to Families with 
Dependent Children (AFDC) in New Jersey participate 
in vocational assessment and counseling, if their 
youngest child is over 2 years of age, and impose 
financial penalties for non-participation. 

• Allow children to remain AFDC-eligible if the AFDC 
mother marries someone other than the natural father 
and the family income is below 150 percent of the 
Federal poverty level (FPL), but give no AFDC payment 
increase for any child born while a family is on welfare. 

• Expand education and employment activities, and 
disregard more of initial earnings, while also allowing 
two-parent families to have the same earnings as single- 
parent families before losing AFDC eligibility. 

• Allow these families who work their way off welfare to 
have a 24-month Medicaid extension, with no income 
limit during the extension period. (Current law provides 
a 6-month Medicaid extension, regardless of income, 
with an additional 6 months contingent upon earnings 
below 185 percent of the FPL.) 

Medicaid waivers were required in order to implement the 
Medicaid transition benefit. 

Status: Approximately 20 percent of the AFDC population 
is participating in the Family Development Program. 
With the August 22, 1996 enactment of the Personal 
Responsibility and Work Opportunity Reconciliation Act 
of 1996 (PRWORA), it is anticipated that the Title IV-A 
component of this demonstration will be modified. 
However, the impact of the PRWORA is being analyzed. 

96-040 Oakland's Enhanced Enterprise Community: 
Community Building Team Program 

Project No.: 1 l-W-00072/9-01 

Period: February 1 996-February 2006 

Award: Waiver-only Project 



Theme 3: Meeting the Needs of Vulnerable Populations 



143 



Principal 
Investigator: 

Awardee: 



HCFA Project 
Officer: 



Eloise Anderson 

Department of Social Services 

744 P Street 

Sacramento, C A 95814 

Alisa Adamo 

Office of State Health Reform 

Demonstrations 



Description: The demonstration project is part of the larger 
empowerment zone/enterprise community effort 
authorized by Congress. The purpose of the empowerment 
zone legislation is to provide Federal support for 
innovative, locally-designed efforts to improve the quality 
of life in low income urban communities. It provides an 
opportunity for cities which have been designated 
empowerment zones or enterprise communities to develop 
innovative programs to bring economic self-sufficiency 
and revitalization to their most distressed areas. Six urban 
empowerment zones and 65 enterprise communities were 
designated on the basis of community-based strategic 
plans which presented comprehensive economic self- 
sufficiency community revitalization. The focus of the 
programs is on comprehensive neighborhood 
revitalization, rather than on welfare reform. One of the 
benefits of the designation is the prompt waiver of 
regulations preventing creative and effective revitalization 
programs. This was the first empowerment zone/enter- 
prise community waiver request. 

In December 1994, Oakland was designated as an 
enhanced enterprise community (EEC) and granted 
$3 million in Social Services Block Grant funds. The 
EEC is part of an ambitious large- scale, multi- 
dimensional strategic plan for Oakland. Oakland's project 
is based on the assumption that single-purpose 
interventions — whether they be in housing, job training, 
social services, or health care — will not suffice to 
revitalize distressed neighborhoods and create economic 
self sufficiency among the residents of those 
neighborhoods. Instead, the enterprise community 
demonstration program in concentrated areas includes 
multi-dimensional interventions and participation from all 
facets of community institutions. The enterprise 
community strategy places community residents in the 
position of the key implementers of the program, and 
thereby moves them from the experience of dependency to 
the experience of empowerment to change their 
communities and their own lives. 

The Community Building Team (CBT) program is the 
central empowerment strategy of Oakland's enterprise 
community. The hypothesis of the CBT program is that 
individuals who are placed in a position of leadership and 
given an opportunity to be resource to their community 
will be motivated to develop their own potential and will 



be good role models in their community. The CBT 
program blends job and skills training for EEC area 
residents with an opportunity for them to directly assist in 
their neighborhoods' revitalization. 

Six CBTs have been established in six target area and are 
comprised of six area residents. Approximately half of the 
team members are Aid to Families with Dependent 
Children (AFDC) recipients. The teams will operate for 
2 years as they identify problems and work with the 
neighborhood to develop solutions. During months 1-12, 
the participants receive a cash work and training stipend. 
Participants are also being provided with transportation, 
child care, and health insurance, as necessary. 
Additionally, during this time the participants will 
undergo education and job skills assessment to identify 
remedial educational needs and job interests. At the end 
of year one, participants will be placed in education or 
internship environments, and a $5,000 stipend will be 
provided to the training or educational institution. 

The CBT program is the core of Oakland's EEC's 
empowerment efforts, and the project required various 
waivers from Administration for Children and Families 
and the Health Care Financing Administration (HCFA). 
The waivers from HCFA disregard the project's payments 
to AFDC and Medi-Cal recipients when establishing 
eligibility or computing grant levels. 

Status: The project began operations in February 1996. 



95-027 OhioCare 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00023/5 

January 1 995-December 2000 

Waiver-only Project 

Bill Ryan 

Ohio Department of Human Services 

30 East Broad Street 

Columbus, OH 43266-0423 

Rose M. Hatten 

Office of State Health Reform 

Demonstrations 



Description: The section 1115 waiver demonstration 
entitled "OhioCare" was approved January 17, 1995, by 
the Health Care Financing Administration. OhioCare is a 
statewide health care reform program that will expand 
coverage to include Ohio's uninsured population with 
incomes of up to 100 percent of the Federal poverty level. 
Ohio expects up to 500,000 additional recipients to 
receive Medicaid benefits under this program. Under 
OhioCare, the State will enroll all new eligibles and 
current Medicaid recipients into managed-care plans. 
Also, OhioCare will test the use of managed care for 



144 



Theme 3: Meeting the Needs of Vulnerable Populations 



special health-related services currently administered by 
State agencies such as the Departments of Mental Health 
and Drug and Alcohol Addiction Services. Demonstration 
waivers have been awarded for a 5 -year period. 

Status: The demonstration was implemented on 
July 1. 1996, and is currently enrolling only Medicaid 
eligibles. Seven counties have implemented mandatory 
enrollment in health maintenance organizations (HMOs); 
another 10 counties have voluntary HMO enrollment. The 
expansion of coverage to the uninsured population and the 
use of managed care for special health-related services has 
been postponed. No date has been set for the 
implementation of those program elements. 

96-008 Oklahoma SoonerCare Demonstration 



Project No. 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00048 6 
October 1 995-June 200 1 
Waiver-only Project 

Garth Splinter 

Oklahoma Health Care Authority 

4545 North Lincoln Boulevard 

Oklahoma City, OK 73105 

Cynthia M. Shirk 

Office of State Health Reform 

Demonstrations 



Description: SoonerCare fosters the creation of a 
managed-care infrastructure in urban and rural areas, thus 
increasing access to primary care for beneficiaries 
throughout the State and allowing for greater financial 
predictability of the State Medicaid program. SoonerCare 
uses fully capitated delivery systems in urban areas and 
requires urban plans to be "rural partners" by expanding 
their provider networks into adjacent rural areas. The 
urban health plan/rural partner program was implemented 
July 1, 1996, and 73,226 Aid to Families with Dependent 
Children (AFDC) and AFDC-related beneficiaries are 
currently enrolled. In rural areas without managed-care 
organizations, a partially capitated primary care physician/ 
case management (PCP/CM) model is used. The PCP/CM 
program was piloted in a tri-county area beginning April 
1, 1996 and was implemented statewide on October 1, 
1996. The PCP/CM program currently serves 51,907 
beneficiaries. This includes Aid to Families with 
Dependent Children (AFDC) and AFDC-related 
populations, as well as beneficiaries who are aged, blind, 
and disabled (ABD) for primary care services only. The 
State plans to implement the program for the entire non- 
institutionalized ABD population July 1, 1997. 

Status: Implementation began April 1, 1996. 



84-008 On Lok's Risk-Based Community Care 
Organization for Dependent Adults: California 
Department of Health Services (Formerly, On Lok's 
Risk-Based Community Care Organization for Dependent 
Adults) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandates: 



ll-P-98334 

November 1983— Indefinite 

Waiver only Project 

Grant 

Louise Nava 

California Department of Health 

Services 

714/744 P Street 

P. O. Box 942732 

Sacramento, CA 94234-7320 

Stefan N. Miller 

Division of Aging and Disability 

Social Security Amendments of 1983 
(Public Law 98-21) Consolidated 
Omnibus Budget Reconciliation Act of 
1985 (Public Law 99-272) 



Description: As mandated by sections 603(c)(1) and (2) of 
Public Law 98-21, the Health Care Financing 
Administration granted Medicare waivers to On Lok 
Senior Health Services and Medicaid waivers to the 
California Department of Health Services. Together, these 
waivers permitted On Lok to implement an at-risk, 
capitated payment demonstration in which more than 300 
frail elderly persons, certified by the California 
Department of Health Services for institutionalization in a 
skilled nursing facility, are provided a comprehensive 
array of health and health-related services in the 
community. The current demonstration maintains On 
Lok's comprehensive community -based program but has 
modified its financial base and reimbursement 
mechanism. All services are paid for by a predetermined 
capitated rate from both the Medicare and Medicaid 
(Medi-Cal) programs. The Medicare rate is based on the 
average per capita cost for the San Francisco County 
Medicare population. The Medi-Cal rate is based on the 
State's computation of current costs for similar Medi-Cal 
recipients, using the formula for prepaid health plans. 
Individual participants may be required to make 
copayments, spend down income, ordivest assets, based 
on their financial status and eligibility for either or both 
programs. On Lok has accepted total risk beyond the 
capitated rates of both Medicare and Medi-Cal, with the 
exception of the Medicare payment for end stage renal 
disease. The demonstration provides service funding only 
under the waivers. Research and development activities 
are funded through private foundations. 



Theme 3: Meeting the Needs of Vulnerable Populations 



145 



Status: Section 9220 of Public Law 99-272 has extended 
On Lok's Risk-Based Community Care Organization for 
Dependent Adults indefinitely, subject to the terms and 
conditions in effect as of July 1. 1985, with the exception 
of the requirements relating to data collection and 
evaluation. 

84-001 On Lok's Risk-Based Community Care 
Organization for Dependent Adults: On Lok Senior 
Health Services (Formerly, On Lok's Risk-Based 
Community Care Organization for Dependent Adults) 

Project No.: 95-P-98246 

Period: November 1983— Indefinite 

Funding: Waiver only Project 

Award: Grant 

Principal 

Investigator: Sue Wong 

Awardee: On Lok Senior Health Services 

1333 Bush Street 

San Francisco, CA 94109 
HCFA Project Stefan N. Miller 
Officer: Division of Aging and Disability 

Mandates: Social Security Amendments of 1983 

(Public Law 98-21) Consolidated 
Omnibus Budget Reconciliation Act of 
1985 (Public Law 99-272) 

Description: As mandated by sections 603(c)(1) and (2) of 
Public Law 98-21, the Health Care Financing 
Administration granted Medicare waivers to On Lok 
Senior Health Services and Medicaid waivers to the 
California Department of Health Services. Together, these 
waivers permitted On Lok to implement an at-risk, 
capitated payment demonstration in which more than 300 
frail elderly persons, certified by the California 
Department of Health Services for institutionalization in a 
skilled nursing facility, are provided a comprehensive 
array of health and health-related services in the 
community. The current demonstration maintains On 
Lok's comprehensive community-based program but has 
modified its financial base and reimbursement 
mechanism. All services are paid for by a predetermined 
capitated rate from both the Medicare and Medicaid 
(Medi-Cal) programs. The Medicare rate is based on the 
average per capita cost for the San Francisco county 
Medicare population. The Medi-Cal rate is based on the 
State's computation of current costs for similar Medi-Cal 
recipients, using the formula for prepaid health plans. 
Individual participants may be required to make 
copayments, spenddown income, or divest assets based on 
their financial status and eligibility for either or both 
programs. On Lok has accepted total risk beyond the 
capitated rates of both Medicare and Medi-Cal, with the 
exception of the Medicare payment for end stage renal 
disease. The demonstration provides service funding only 



under the waivers. Research and development activities 
are funded through private foundations. 

Status: Section 9220 of Public Law 99-272 has extended 
On Lok's Risk-Based Community Care Organization for 
Dependent Adults indefinitely, subject to the terms and 
conditions in effect as of July 1, 1985, with the exception 
of the requirements relating to data collection and 
evaluation. On Lok is continuing to develop collaborative 
projects with other organizations in the San Francisco Bay 
area. A pilot agreement with the Institute on Aging (IOA) 
has been completed and the two organizations have 
entered in a venture agreement in which IOA will be 
establishing an adult day health center and operating it 
under the rules of the Program of All-inclusive Care for 
the Elderly protocol. The site will be established in the 
Richmond area of San Francisco. On Lok will provide 
quality assurance oversight as well as marketing and 
enrollment support. IOA will receive a portion of On 
Lok's capitation it receives via the HCFA demonstration 
and a portion will be retained by On Lok to cover 
administratrive expenses. 

96-072 Oral Rehydration Therapy and Children 
Immunization Initiatives for Infants and Children of 
AFDC Beneficiaries from Inner-City African- 
American Communities 

Project No.: 20-C-90706/3-01 

Period: September 1 996-September 1998 

Funding: $319,834 

Award: Cooperative Agreement 

Principal 

Investigator: Anna McPhatter, Ph.D. 

Awardee: Morgan State University 

Coldspring Lane and Hillen Road 

Baltimore, MD 21239 
HCFA Project Richard Bragg 
Officer: Division of Aging and Disability 

Description: The goal of this collaborative research effort 
of Morgan, Coppin State, and Norfolk State Universities 
is to design, implement, and evaluate a community-based 
self-help demonstration health project aimed at increasing 
the awareness and utilization of immunization against 
common childhood diseases and oral rehydration therapy 
(ORT) for diarrheal disease treatment among 225 targeted 
African-American families of Aid to Families with 
Dependent Children beneficiaries. This is a demonstration 
project with three goals: 

• To increase the immunization rate among its 
participants to 80 percent. 

• To increase the use of oral rehydration therapy from 
percent to 30 percent. 

• To enhance the knowledge of ORT among child care 
and health care providers. 



146 



Theme 3: Meeting the Needs of Vulnerable Populations 



Status: This project is in its early design phase. 
93-038 Oregon Reform Demonstration 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-P-90 160/0 
April 1993-January 
Waiver only 
Grant 



1999 



Lynn Read 

Oregon Department of 

Human Resources 

500 Summer Street, NE. 

Salem, OR 97310 

Bruce R. Johnson 

Office of State Health Reform 

Demonstrations 



Description: The Oregon Reform Demonstration is an 
innovative program of private insurance reform, employer 
coverage, managed care, and restructured Medicaid 
benefits for both the Medicaid-eligible and the uninsured 
populations. The demonstration is scheduled to operate 
between February 1, 1994, and January 31, 1999. The 
demonstration will extend Medicaid eligibility for 
Oregonians whose income is below the Federal poverty 
level, regardless of age, sex, and family status. Since the 
number of persons eligible for benefits will increase 
substantially, Oregon will implement two mechanisms for 
containing costs: prioritization of condition-specific 
treatments and procedures that will be included in the 
Medicaid benefit package, and managed-care initiatives to 
enhance coordination of care and provide incentives for 
controlling costs. Mental health and chemical dependence 
services were incorporated into the Oregon Health Plan 
(OHP) benefit package for up to 25 percent of the eligible 
population with the implementation of Phase II in January 
1995. In March 1995, Phase II eligibles, which include 
aged, blind, disabled, and foster-care children, were added 
to the OHP. Nursing facilities and home and community- 
based services will not be affected by the demonstration. 

Status: The State began enrollment in February 1994. As 
of July 1996, approximately 176,000 current Medicaid 
eligibles and 1 12,000 previously uninsured individuals 
had enrolled in the OHP, along with 76,000 aged, blind, 
disabled, and foster-care children added to OHP under 
Phase II. The delivery system consists of 16 fully 
capitated health plans, 4 partially capitated physician care 
organizations, 7 dental care organizations, and 9 mental 
health organizations. There are currently 869 primary- 
care case managers also under contract to provide care in 
counties without sufficient prepaid health plans (an 
increase from 387 in June 1994). In the other counties 
where a sufficient number of plans have contracted, 
participants must select a plan or be assigned to one. As a 
result of budget cuts by the State legislature, in 1995, 



Oregon was granted authority to impose additional 
eligibility requirements for new eligibles, impose 
premiums (with waivers of premium amounts in instances 
of hardship), and to move the funding line of covered 
condition/ treatments pairs, eliminating 25 previously 
covered services from the OHP benefit package. On 
September 30, 1996, Oregon was granted authority to 
modify the enrollment and disenrollment process for OHP 
participants. The State has also requested elimination of 
eight additional condition/ treatment pairs from the OHP 
benefit package, but HCFA has not yet made a decision on 
the State's request. 

95-065 Pennsylvania Welfare Reform: 
Pennsylvania Pathways to Independence 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00044/3 

November 1994-March 2000 

Waiver-only Project 

Feather Houstoun 
Pennsylvania Department of 
Public Welfare 
P. O Box 2675 
Harrisburg, PA 17105-2675 
Joan Peterson, Ph.D. 
Office of State Health Reform 
Demonstrations 



Description: In Lancaster County, participants enter into 
written agreements intended to move them to employ- 
ment. In the third month of employment, recipient 
families receive a benefit consisting of an Aid to Families 
with Dependent Children (AFDC) payment plus the cash 
equivalent of the family's Food Stamp allotment; AFDC 
earned-income disregards and Food Stamp deductions 
have been replaced with a deduction of $200 plus 
30 percent; resource limits have been increased from 
$2,000 to $5,000; and recipients may exclude the equity 
value of one vehicle up to $7,500, as well as tax refunds 
and deposits into educational and retirement accounts. 
Aid to Families with Dependent Children-Unemployed 
Parent (AFDC-UP) eligibility and work activity 
requirements have been eliminated, and full-time students 
through 20 years of age may receive AFDC. Child-care 
providers receive direct payment to cover the cost of care 
up to the established local-market rate ceiling. 
Transitional child care and Medicaid are provided to 
families with earned income up to 235 percent of Federal 
poverty level, and case-management services for such 
families may continue for 12 months after assistance ends. 
Transitional Medicaid for cases closed due to receipt of 
child support has been extended to 12 months. 

Status: The State continues to operate this demonstration 
project. With the August 22, 1996 enactment of the 
Personal Responsibility and Work Opportunity 



Theme 3: Meeting the Needs of Vulnerable Populations 



147 



Reconciliation Act of 1996 (PRWORA), it is anticipated 
that the Title IV-A component of this demonstration will 
be modified. However, the impact of the PRWORA is 
being analyzed. 

92-100 Potential of Coordinated Care Targeted to 
Medicare Beneficiaries with Medicaid Coverage 

(Formerly. Long-Term Care Studies (Section 207)) 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 

HCFA Project 
Officer: 



500-89-0047/33 
April 1992-August 
S 18,500 
Contract 



992 



David Kennell 

Lewin/VHI, Inc. 

(See page 17) 

Carolyn Rimes 

Division of Aging and Disability 



Description: This paper discusses the potential for 
coordinating health service delivery and financing among 
the population eligible for both Medicare and Medicaid 
financing (the "dual eligibles"). First, it discussed the 
interactions between Medicare and Medicaid eligibility 
and financing for services and then presented a 
description of the characteristics and health service use by 
the dual eligibles. Second, it explored the potential 
benefits of care coordination and management among this 
population and addressed lessons learned and relevant 
issues in developing coordinated care targeted to the dual 
eligibles. 

Status: This paper found that although dual eligibles 
typically use high amounts of both Medicare and 
Medicaid services (where Medicaid primarily funds 
chronic care services among Medicare beneficiaries), 
there is very little coordination between the two programs. 
Dual eligibles tend to be poor females living in the 
community. Nearly one-third of the noninstitutionalized 
Medicare beneficiaries who are under 65 years of age 
receive Medicaid. The final report is has been submitted 
and is currently under review. 

90-003 Program for All-inclusive Care for the Elderly: 
Beth Abraham Hospital (Formerly, Frail Elderly 
Demonstration: The Program for All-inclusive Care for 
the Elderly) 



Project No.: 
Period: 

Funding: 
Award: 
Principal 
Investigator: 



95-P-99361 
October 1989-January 
(yearly continuation) 
Waiver only Project 
Grant 

Susan Aldrich 



995 



Awardee: 



HCFA Project 
Officer: 

Mandates: 



Beth Abraham Hospital 

612 Allerton Avenue 

Bronx, NY 10467 

Stefan N. Miller 

Division of Aging and Disability 

Omnibus Budget Reconciliation Act of 
1986 (Public Law 99-509)Omnibus 
Budget Reconciliation Act of 1987 
(Public Law 100-203) Omnibus Budget 
Reconciliation Act of 1990 
(Public Law 101-508) 



Description: Mandated by Public Law 99-509, as 
amended by section 41 18(g)(l)(2) of Public Law 100-203 
and section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 1 5 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care includes — as 
core services — the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act 
of 1987. 

Status: Expansion into Westchester County has taken 
place and an expansion of services will take place at 
another site as soon as is feasible. 

92-005 Program for All-inclusive Care for the Elderly: 
Bienvivir Senior Health Services (Formerly, Frail 
Elderly Demonstration: The Program for All-inclusive 
Care for the Elderly) 



Project No.: 


95-P-99649 


Period: 


December 1991-May 1995 




(yearly continuation) 


Funding: 


Waiver only Project 


Award: 


Grant 



148 



Theme 3: Meeting the Needs of Vulnerable Populations 



Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandates: 



Rosemary Castillo 

Bienvivir Senior Health Services 

6000 Welch, Suite A-2 

El Paso. TX 77905-1753 

Stefan N. Miller 

Division of Aging and Disability 

Omnibus Budget Reconciliation Act of 
1986 (Public Law 99-509)Omnibus 
Budget Reconciliation Act of 1987 
(Public Law 100-203) Omnibus Budget 
Reconciliation Act of 1990 
(Public Law 101-508) 



Description: Mandated by Public Law 99-509, as 
amended by section 41 18(g)(l)(2) of Public Law 100-203 
and section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 15 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care includes — as 
core services — the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act 
of 1987. 

Status: This site has received a Housing and Urban 
Development 202 grant to build a residential structure 
and is in the process of implementing this opportunity. 

95-092 Program for All-inclusive Care for the Elderly: 
California Department of Health Services (Formerly, 
Frail Elderly Demonstration: The Program for All- 
inclusive Care for the Elderly) 



Project No.: 
Period: 



ll-P-90485 

April 1995-March 1998 

(yearly continuation) 



Funding: Waiver only Project 

Award: Grant 

Principal 

Investigator: Louise Nava 

Awardee: Department of Health Services 

712/744 P Street 
P. O. Box 942732 
Sacramento, California 95814 

HCFA Project Stefan N. Miller 

Officer: Division of Aging and Disability 

Mandates: Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509)Omnibus 
Budget Reconciliation Act of 1987 
(Public Law 100-203) Omnibus Budget 
Reconciliation Act of 1990 
(Public Law 101-508) 

Description: Mandated by Public Law 99-509, as 
amended by section 41 18(g)(l)(2) of Public Law 100-203 
and section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 1 5 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care includes — as 
core services — the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act of 
1987. The 10 sites and their State Medicaid agencies that 
have been granted waiver approval to provide services are 
East Boston Geriatric Services, Inc.; Providence Medical 
Center; Total Longterm Care, Inc.; Rochester General 
Hospital; Sutter Health System; Beth Abraham Hospital; 
Richland Memorial Hospital; Bienvivir Senior Health 
Services; Community Care Organization; and Center for 
Elders' Independence. 

Status: The State continues to be supportive of the site's 
program. 



Theme 3: Meeting the Needs of Vulnerable Populations 



149 



95-093 Program for All-inclusive Care for the Elderly: 
Center for Elders' Independence (Formerly, Frail 
Elderly Demonstration: The Program for All-inclusive 
Care for the Elderly) 

Project No.: 95-P-90653 

Period: April 1995-March 1998 

(yearly continuation) 
Funding: Waiver only Project 

Award: Grant 

Principal 

Investigator: Peter Szutu 
Awardee: Center for Elders' Independence 

1411 East 31st Street, Ward B 2 

Oakland, CA 94602 
HCFA Project Stefan N. Miller 
Officer: Division of Aging and Disability 

Mandates: Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509)Omnibus 
Budget Reconciliation Act of 1987 
(Public Law 100-203) Omnibus Budget 
Reconciliation Act of 1990 
(Public Law 101-508) 

Description: Mandated by Public Law 99-509, as 
amended by section 41 18(g)(l)(2) of Public Law 100-203 
and section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 15 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care includes, as 
core services, the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act 
of 1987. 

Status: The second adult day health center opened in 
December 1995 and is located in a five story residential 
structure. Centers for Elders' Independence has access to 



some of these apartments for use by enrollees. Con- 
sideration is being given to developing a third site in 
nearby Berkeley. 

91-066 Program of All-Inclusive Care for the Elderly: 
Colorado Department of Social Services (Formerly, 
Frail Elderly Demonstration: The Program for 
All-Inclusive Care for the Elderly) 

Project No.: ll-P-99646 

Period: August 1991-September 1994 

(yearly continuation) 
Funding: Waiver only 

Award: Grant 

Principal 

Investigator: Carol Workman-Allen 
Awardee: Colorado Department of Social Services 

1575 Sherman Street 

Denver, CO 80203-1714 
HCFA Project Stefan N. Miller 
Officer: Division of Aging and Disability 

Mandates: Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) Omnibus 
Budget Reconciliation Act of 1987 
(Public Law 100-203) Omnibus Budget 
Reconciliation Act of 1990 
(Public Law 101-508) 

Description: Mandated by Public Law 99-509, as 
amended by section 41 18(g)(l)(2) of Public Law 100-203 
and section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 15 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-Inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care includes — as 
core services — the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act of 
1987. The ten sites and their State Medicaid agencies that 



50 



Theme 3: Meeting the Needs of Vulnerable Populations 



have been granted waiver approval to provide services 
are: East Boston Geriatric Services, Inc.; Providence 
Medical Center; Total Longtenn Care, Inc. (TLC); 
Rochester General Hospital; Sutter Health System; Beth 
Abraham Hospital; Richland Memorial Hospital; 
Bienvivir Senior Health Services; Community Care 
Organization; and Center for Elders' Independence. 

Status: The Colorado Foundation for Medical Care 
(Medicaid's Peer Review Organization) annually reviews 
TLC's quality assurance prodecures. No issues of concern 
were identified this past year. 

90-045 Program for All-Inclusive Care for the Elderly: 
Community Care Organization (Formerly, Frail Elderly 
Demonstration: The Program for All-inclusive Care for 
the Elderly) 

Project No.: 95-P-99628 

Period: August 1990-October 1994 

(yearly continuation) 
Funding: Waiver only 

Award: Grant 

Principal 

Investigator: Kirby G. Shoaf 
Awardee: Community Care Organization 

5228 West Fond du Lac Avenue 

Milwaukee, WI 53216 
HCFA Project Stefan N. Miller 
Officer: Division of Aging and Disability 

Mandates: Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 
Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 

Description: Mandated by Public Law 99-509, as 
amended by section 41 18(g)(l)(2) of Public Law 100-203 
and section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 15 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care includes, as 
core services, the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 



health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act 
of 1987. 

Status: During the past year, Community Care 
Organization began offering services at the fourth adult 
day health center site. 

92-101 Program for All-inclusive Care for the 
Elderly Data Management, 1992-95 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-92-0007 

March 1992-August 1995 

$613,014 

Contract 

Marleen L. Clark, Ph.D. 

On Lok Senior Health Services 

1333 Bush Street 

San Francisco, CA 94109 

Kay Lewandowski 

Division of Aging and Disability 



Description: The purpose of this project is to provide 
continuing data management throughout the Program for 
All-inclusive Care for the Elderly (PACE) demonstration 
period to ensure that a valid, reliable data set is 
maintained for monitoring project operations and for use 
by the Health Care Financing Administration's 
independent evaluator. The PACE demonstration 
replicates a unique model of managed-care service 
delivery for very frail community-dwelling elderly 
persons, most of whom are dually eligible for Medicare 
and Medicaid coverage and all of whom are assessed as 
being eligible for nursing home placement according to 
the standards established by the participating States. 
DataPACE maintains a data set on PACE enrollees, 
including demographic and enrollment information, health 
and functional status, and service use. For the PACE 
demonstration project, On Lok has established a minimum 
dataset and has implemented data collection procedures at 
the PACE sites for this data set. This dataset includes the 
variables and program information originally designed to 
be used by evaluators. 

Status: This contract has been concluded. 

95-059 Program for All-inclusive Care for the 
Elderly Data Management, 1995-98 

Project No.: 500-95-0035 



Theme 3: Meeting the Needs of Vulnerable Populations 



151 



Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



September 
$ 590,630 
Contract 



995-August 1998 



Marleen L. Clark, Ph.D. 

On Lok Senior Health Services 

1333 Bush Street 

San Francisco, CA 94109 

Kay Lewandowski 

Division of Aging and Disability 



Description: The purpose of this contract is to provide 
data management for the Program of All-inclusive Care 
for the Elderly (PACE) demonstration period to ensure 
that a valid, reliable data set is maintained for monitoring 
project operations and for use by the Health Care 
Financing Administration's independent evaluator. This 
is a continuation of the previous contract with On Lok, 
Inc. to provide this service. DataPACE maintains a data 
set on PACE enrollees and manages data collection 
procedures at the PACE sites. In the course of this second 
contract, service utilization data are scheduled to be used 
by the PACE demonstration program's independent 
evaluator. 

Status: The DataPACE software and data management 
routines have been implemented at all sites and continue 
to be used to monitor data quality and provide feedback to 
the sites. The first round of data transmissions to the 
independent evaluator have taken place. 

90-010 Program for All-inclusive Care for the Elderly: 
East Boston Geriatric Services, Inc. (Formerly, Frail 
Elderly Demonstration: The Program for All-inclusive 
Care for the Elderly) 

Project No.: 95-P-99357 

Period: October 1989-May 1994 

(yearly continuation) 
Funding: Waiver only Project 

Award: Grant 

Principal 

Investigator: Jean Masland 
Awardee: East Boston Geriatric Services, Inc. 

1 Gove Street 

Boston, MA 02128 
HCFA Project Stefan N. Miller 
Officer: Division of Aging and Disability 

Mandates: Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 
Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 



Description: Mandated by Public Law 99-509, as amended 
by section 41 18(g)(l)(2) of Public Law 100-203 and 
section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 15 sites, the model of care 
developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care includes, as 
core services, the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act 
of 1987. 

Status: East Boston is expecting to take possession of its 
third Housing and Urban Development, section 202 
building by Fall 1997. The site continues to to provide 
technical assistance to the six pre-PACE sites being 
developed in the Boston and Worcester areas. All of these 
sites are currently operating. 

90-009 Program for All-inclusive Care for the Elderly: 
Massachusetts State Department of Public Welfare 

(Formerly, Frail Elderly Demonstration: The Program for 
All-inclusive Care for the Elderly) 

Project No.: ll-P-99356 

Period: October 1989-May 1994 

(yearly continuation) 
Funding: Waiver only Project 

Award: Grant 

Principal 

Investigator: Diane Flanders 
Awardee: Massachusetts Department of 

Public Welfare 

180Tremont Street 

Boston, MA 02111 
HCFA Project Stefan N. Miller 
Officer: Division of Aging and Disability 



152 



Theme 3: Meeting the Needs of Vulnerable Populations 



Mandates: Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 
Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 

Description: Mandated by Public Law 99-509, as amended 
by section 41 18(g)(l)(2) of Public Law 100-203 and 
section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 15 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-inclusive Care 
for the Elderly (PACE) demonstration replicates a unique 
model of managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care includes, as 
core services, the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act of 
1987. The ten sites and their State Medicaid agencies that 
have been granted waiver approval to provide services are 
EastBoston Geriatric Services, Inc.; Providence Medical 
Center; Total Longterm Care, Inc.; Rochester General 
Hospital; Sutter Health System; Beth Abraham Hospital; 
Richland Memorial Hospital; Bienvivir Senior Health 
Services; Community Care Organization; and Center for 
Elders' Independence. 

Status: The State is developing six additional PACE sites. 

92-033 Program for All-inclusive Care for the Elderly: 
New York State Department of Social Services, 
March 1992-March 1995 (Formerly, Frail Elderly 
Demonstration: The Program for All-inclusive Care for 
the Elderly) 

Project No.: ll-P-99357 

Period: March 1992-March 1995 

(yearly continuation) 
Funding: Waiver only Project 



Award: 
Principal 
Investigator: 
Awardee: 



HCFA Project 

Officer: 

Mandates: 



Grant 

Christopher Rush 

New York State Department of 

Social Services 

40 North Pearl Street 

Albany, NY 12243-0001 

Stefan N. Miller 

Division of Aging and Disability 

Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 
Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 



Description: Mandated by Public Law 99-509, as 
amended by section 41 18(g)(l)(2) of Public Law 100-203 
and section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 1 5 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-Inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care includes — as 
core services — the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act of 
1987. The 10 sites and their State Medicaid agencies that 
have been granted waiver approval to provide services 
are: East Boston Geriatric Services, Inc.; Providence 
Medical Center; Total Longterm Care, Inc.; Rochester 
General Hospital; Sutter Health System; Beth Abraham 
Hospital; Richland Memorial Hospital; Bienvivir Senior 
Health Services; Community Care Organization; and the 
Center for Elders' Independence. 

Status: The State continues to find that the site is in 
compliance with applicable State and Federal 
requirements. 



Theme 3: Meeting the Needs of Vulnerable Populations 



153 



90-004 Program for All-inclusive Care for the Elderly: 
New York State Department of Social Services, 
October 1989-January 1995 (Formerly, Frail Elderly 
Demonstration: The Program for All-inclusive Care for 
the Elderly) 

Project No.: ll-P-99360 

Period: October 1989-January 1995 

(yearly continuation) 
Funding: Waiver only Project 

Award: Grant 

Principal 

Investigator: Christopher Rush 
Awardee: New York State Department of 

Social Services 

40 North Pearl Street 

Albany, NY 12243-0001 
HCFA Project Stefan N. Miller 
Officer: Division of Aging and Disability 

Mandates: Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 
Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 

Description: Mandated by Public Law 99-509, as 
amended by section 41 18(g)(l)(2) of Public Law 100-203 
and section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 15 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care include, as core 
services, the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act of 
1987. The ten sites and their State Medicaid agencies that 
have been granted waiver approval to provide services are 
East Boston Geriatric Services, Inc.; Providence Medical 



Center; Total Longterm Care, Inc.; Rochester General 
Hospital; Sutter Health System; Beth Abraham Hospital; 
Richland Memorial Hospital; Bienvivir Senior Health 
Services; Community Care Organization; and Center for 
Elders' Independence. 

Status: During the year, the State performed a survey of 
Beth Abraham's program and found it to be in compliance 
with State and Federal laws and regulations. 

90-007 Program for All-inclusive Care for the Elderly: 
Oregon State Department of Human Services 

(Formerly, Frail Elderly Demonstration: The Program for 
All-Inclusive Care for the Elderly) 



Project No.: 

Period: 

continuation) 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandates: 



ll-P-99358 

October 1989-May 1994 (yearly 

Waiver only Project 
Grant 

Rita Litwiller 

Oregon State Department of 

Human Services 

313 Public Service Building 

Salem, OR 97310 

Stefan N. Miller 

Division of Aging and Disability 

Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 
Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 



Description: Mandated by Public Law 99-509, as 
amended by section 41 18(g)(l)(2) of Public Law 100-203 
and section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 15 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care includes, as 
core services, the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 



154 



Theme 3: Meeting the Needs of Vulnerable Populations 



off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act of 
1987. The ten sites and their State Medicaid agencies that 
have been granted waiver approval to provide services are 
EastBoston Geriatric Services, Inc.; Providence Medical 
Center; Total Longterm Care, Inc.; Rochester General 
Hospital; Sutter Health System; Beth Abraham Hospital; 
Richland Memorial Hospital; Bienvivir Senior Health 
Services; Community Care Organization; and Center for 
Elders' Independence. 

Status: The State continues to support this program. 

90-008 Program for All-inclusive Care for the Elderly: 
Providence Medical Center (Formerly, Frail Elderly 
Demonstration: The Program for All-inclusive Care for 
the Elderly) 

Project No.: 95-P-99359 

Period: October 1989-May 1994 

(yearly continuation) 
Funding: Waiver only Project 

Award: Grant 

Principal 

Investigator: Don Keister 
Awardee: Providence Medical Center 

4805 Northeast Glisan Street 

Portland, OR 97213 
HCFA Project Stefan N. Miller 
Officer: Division of Aging and Disability 

Mandates: Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 
Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 

Description: Mandated by Public Law 99-509, as amended 
by section 41 18(g)(l)(2) of Public Law 100-203 and 
section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 15 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care includes, as 
core services, the provision of adult day health care and 



multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act 
of 1987. 

Status: A new 42 -unit housing structure, Cully Place, is 
scheduled for completion in 1996. Cully Place will also 
contain the third adult day health center and will be able 
to provide services to 1 10 enrollees. Providence Elder 
Place is also considering expanding its services beyond 
Multnomah County. 

90-043 Program for All-inclusive Care for the Elderly: 
Richland Memorial Hospital (Formerly, Frail Elderly 
Demonstration: The Program of All-Inclusive Care for the 
Elderly) 

Project No.: 95-P-99630 

Period: August 1990-September 1994 

(yearly continuation) 
Funding: Waiver only Project 

Award: Grant 

Principal 

Investigator: Judy Baskins 
Awardee: Richland Memorial Hospital 

Fifteen Richland Medical Park 

Columbia, SC 29203 
HCFA Project Stefan N. Miller 
Officer: Division of Aging and Disability 

Mandates: Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 
Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 

Description: Mandated by Public Law 99-509, as 
amended by section 41 18(g)(l)(2) of Public Law 100-203 
and section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 1 5 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 



Theme 3: Meeting the Needs of Vulnerable Populations 



155 



all of whom are assessed as being eligible for nursing 
home placement, according to the standards established by 
participating States. The model of care includes — as core 
sen ices — the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services areprovided on site at the adult day health 
center whenever possible. Hospital, nursing home, home 
health, and other specialized services are provided off site. 
Transportation is provided to all enrolled members who 
require it. This model is financed through prospective 
capitation of both Medicare and Medicaid payment to the 
provider. Demonstration sites are to assume financial risk 
progressively over 3 years, as stipulated in the Omnibus 
Budget Reconciliation Act 
of 1987. 

Status: Renovations at the adult day health centers 
(ADHC) have been completed and four ADHC's are now 
operating. In April, the site opened Palmetto Senior 
Community with eight, two-bedroom units to provide an 
alternative to nursing facility care. 

92-032 Program for All-Inclusive Care for the Elderly: 
Rochester General Hospital (Formerly, Frail Elderly 
Demonstration: The Program for All-Inclusive Care for 
the Elderly) 

Project No.: 95-P-99660 

Period: March 1992-March 1995 

(yearly continuation) 
Funding: Waiver-only Project 

Award: Grant 

Principal 

Investigator: Kathryn McGuire 
Awardee: Rochester General Hospital 

31 1 Alexander Street 

Rochester, NY 14604 
HCFA Project Stefan N. Miller 
Officer: Division of Aging and Disability 

Mandates: Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 
Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 

Description: Mandated by Public Law 99-509, as 
amended by section 41 18(g)(l)(2) of Public Law 100-203 
and section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 15 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco. California. The Program for All-inclusive Care 
for the Elderly demonstration replicates a unique model of 



managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established by 
participating States. The model of care includes, as core 
services, the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act 
of 1987. 

Status: The site continues to provide technical assistance 
to two prospective PACE sites — The Eddy of Troy, 
New York, and Independent Living Services in Syracuse, 
New York. 

90-044 Program for All-inclusive Care for the Elderly: 
South Carolina State Health and Human Services 
Finance Commission (Formerly, Frail Elderly 
Demonstration: The Program for All-Inclusive Care for 
the Elderly) 

Project No.: ll-P-99629 

Period: August 1 990-September 1994 

(yearly continuation) 
Funding Waiver-only Project 

Award: Grant 

Principal 

Investigator: Nicki Harvey 
Awardee: South Carolina State Health and Human 

Services Finance Commission 

P. O. Box 8206 

Columbia, SC 29202-8206 
HCFA Project Stefan N. Miller 
Officer: Division of Aging and Disability 

Mandates: Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 
Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 

Description: Mandated by Public Law 99-509, as 
amended by section 41 18(g)(I)(2) of Public Law 100-203 
and section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 



156 



Theme 3: Meeting the Needs of Vulnerable Populations 



that replicates, in not more than 15 sites, the model of care 
developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care includes — as 
core services — the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act of 
1987. The ten sites and their State Medicaid agencies that 
have been granted waiver approval to provide services are 
East Boston Geriatric Services, Inc.; Providence Medical 
Center; Total Longterm Care, Inc.; Rochester General 
Hospital; Sutter Health System; Beth Abraham Hospital; 
Richland Memorial Hospital; Bienvivir Senior Health 
Services; Community Care Organization; and Center for 
Elders' Independence. 

Status: The State continues to be supportive of Palmetto 
Senior Care's program, and is now in the process of 
developing a client satisfaction survey. 

94-040 Program for All-inclusive Care for the Elderly: 
Sutter Health System 



Project No.: 

Period: 

continuation) 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



95-P-90484 

May 1994-April 1997 (yearly 

Waiver-only Project 
Grant 

Janet Tedesco 

Sutter Health System 

2800 L Street 

Sacramento, CA 95816 

Stefan N. Miller 

Division of Aging and Disability 



Mandates: Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 
Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 

Description: Mandated by Public Law 99-509, as amended 
by section 41 18(g)(l)(2) of Public Law 100-203 and 
section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 15 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care includes, as 
core services, the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act 
of 1987. 

Status: Janet Tedesco was named as the new 
Administrator in November 1996. SSC is in the last year 
of the demonstration's risk-sharing phase. 

92-006 Program for All-inclusive Care for the Elderly: 
Texas Department of Human Services (Formerly, Frail 
Elderly Demonstration: The Program for All-inclusive 
Care for the Elderly) 

Project No.: ll-P-99648 

Period: December 1991— November 1995 

(yearly continuation) 
Funding: Waiver-only Project 

Award: Grant 

Principal 

Investigator: Gerardo Cantu 
Awardee: Texas Department of Human Services 

P. O. Box 149030 (MC-E-601) 

Austin, TX 78714-9030 
HCFA Project Stefan N. Miller 
Officer: Division of Aging and Disability 



Theme 3: Meeting the Needs of Vulnerable Populations 



157 



Mandates: Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 
Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 

Description: Mandated by Public Law 99-509, as amended 
by section 41 18(g)(l)(2) of Public Law 100-203 and 
section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 15 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care includes, as 
core services, the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act of 
1987. The ten sites and their State Medicaid agencies that 
have been granted waiver approval to provide services 
are: East Boston Geriatric Services, Inc.; Providence 
Medical Center; Total Longterm Care, Inc.; Rochester 
General Hospital; Sutter Health System; Beth Abraham 
Hospital; Richland Memorial Hospital; Bienvivir Senior 
Health Services; Community Care Organization; and the 
Center for Elders' Independence. 

Status: The State continues to work very closely with 
Bienvivir Senior Health Services site. The State will 
continue to carry out periodic monitoring reviews and to 
offer administrative and professional assistance. 

91-065 Program for All-inclusive Care for the Elderly: 
Total Longterm Care, Inc. (Formerly, Frail Elderly 
Demonstration: The Program for All-inclusive Care for 
the Elderly) 



Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 

Mandates: 



Grant 

David Reyes 

Total Longterm Care, Inc. 

3202 West Colfax 

Denver, CO 80204 

Stefan N. Miller 

Division of Aging and Disability 

Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 
Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 



Description: Mandated by Public Law 99-509, as 
amended by section 41 18(g)(l)(2) of Public Law 100-203 
and section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 15 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-Inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care includes, as 
core services, the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act 
of 1987. 

Status: There have been no significant changes in Total 
Longterm Care's operation since the last report. 

90-046 Program for All-inclusive Care for the Elderly: 
Wisconsin State Department of Health and Social 
Services (Formerly, Frail Elderly Demonstration: The 
Program for All-Inclusive Care for the Elderly) 



Project No.: 
Period: 

Funding: 



95-P-99647 

August 1991-September 
(yearly continuation) 
Waiver-only Project 



994 



Project No. 
Period: 

Funding: 



ll-P-99627 
August 1990-October 
(yearly continuation) 
Waiver-only Project 



994 



158 



Theme 3: Meeting the Needs of Vulnerable Populations 



Award: 
Principal 
Investigator: 
Awardee: 



HCFA Project 
Officer: 

Mandates: 



Grant 

Ruth Belshaw 

Wisconsin State Department of Health 

and Social Services 

P. O. Box 7850 

Madison, WI 53707-7850 

Stefan N. Miller 

Division of Aging and Disability 

Omnibus Budget Reconciliation Act of 

1986 (Public Law 99-509) 
Omnibus Budget Reconciliation Act of 

1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 



Description: Mandated by Public Law 99-509, as 
amended by section 41 18(g)(l)(2) of Public Law 100-203 
and section 4744 of Public Law 101-508, the Health Care 
Financing Administration will conduct a demonstration 
that replicates, in not more than 15 sites, the model of 
care developed by On Lok Senior Health Services in San 
Francisco, California. The Program for All-inclusive Care 
for the Elderly demonstration replicates a unique model of 
managed-care service delivery for 300 very frail 
community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing 
home placement, according to the standards established 
by participating States. The model of care includes — as 
core services — the provision of adult day health care and 
multidisciplinary case management through which access 
to and allocation of all health and long-term-care services 
are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day 
health center whenever possible. Hospital, nursing home, 
home health, and other specialized services are provided 
off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid 
payments to the provider. Demonstration sites are to 
assume financial risk progressively over 3 years, as 
stipulated in the Omnibus Budget Reconciliation Act of 
1987. The ten sites and their State Medicaid agencies that 
have been granted waiver approval to provide services are 
East Boston Geriatric Services, Inc.; Providence Medical 
Center; Total Longterm Care, Inc.; Rochester General 
Hospital; Sutter Health System; Beth Abraham Hospital; 
Richland Memorial Hospital; Bienvivir Senior Health 
Services; Community Care Organization; and Center for 
Elders' Independence. 

Status: The State continues to be supportive of the PACE 
program and has entered into a contract with a site in 
Madison to furnish pre-PACE services. 



92-029 Program of Preconceptional Intervention for 
Women At Risk for Low-Birth-Weight (LBW) Infants: 
State of Florida 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee 



HCFA Project 
Officer: 



ll-C-90 154/5 
February 1992-May 1998 
$917,324 
Cooperative Agreement 

Gary Crayton, Medicaid Director 

Florida's Agency for Health Care 

Administration 

Medicaid Administration 

P. O. Box 13000 

Tallahassee, FL 32317-3000 

Lori Teichman, Ph.D. 

Division of Health Information and 

Outcomes 



Description: This demonstration project provides 
interconceptional services to women who have had a 
Medicaid-covered pregnancy and who meet at least one of 
the following criteria: (1) delivery of a LBW baby, 
(2) absence of prenatal care, and/or (3) age is 15 years old 
or younger at the time of delivery. The objectives of the 
program are to prevent subsequent pregnancies for at least 
2 years, and to improve the health status of the women 
through behavioral changes. The project is implemented 
by the University of Florida (UF), and the Department of 
Biostatistics. The eligible women who give birth to LBW 
infants are identified subsequent to the deliveries at the 
UF Shands Hospital, the medical site where the majority 
of indigent women in the 10-county demonstration area 
are scheduled for Medicaid-covered deliveries. The 
women who volunteer to participate are randomly 
assigned to either the service or control groups. The 
project services are provided in the clients' homes on a 
one-to-one basis, by paraprofessionals who are known as 
"Resource Mothers." 

Status: The fifth year of the cooperative agreement was 
approved for continuation in the period of June 1, 1996 
through May 31, 1997. In the Year 04 report, it was stated 
that over 500 women were enrolled in the study to date. In 
July 1996, there were 135 women in the control group, 
and 123 women in the service group. The July 1996 report 
indicated that 220 women were in the program at least 1 
full year, and 95 clients had been in the program at least 2 
years. 

93-094 Program Payments and Utilization Trends for 
Medicare Beneficiaries with Disabilities (Formerly, 
Long-Term Care Studies (Section 207)) 

Project No.: 500-89-0047/9 

Period: December 1992— November 1994 

Funding: $ 175,300 



Theme 3: Meeting the Needs of Vulnerable Populations 



159 



Award: 
Principal 
Investigator: 
Awardee: 

HCFA Project 
Officer: 



Contract 

David Kennel 1 

Lewin/VHI. Inc. 

(See page 17) 

Carolyn Rimes 

Division of Aging and Disability 



Description: This study is an extension of the analyses of 
the acute care costs of chronically disabled persons 
completed using the 1984-89 National Long-Term Care 
Survey (NLTCS). This analysis employs recently released 
1989 NLTCS data to examine possible cost shifts for 
groups of persons with very different levels of health and 
functioning. Analyses were made of seven different 
categories of Medicare service (short-stay hospital, home 
health agency, skilled nursing facility, physician, 
outpatient, durable medical equipment, and renal therapy) 
for 1982 to 1990 using Medicare records linked to data on 
community and institutional residents from NLTCS 
1982, 1984, and 1989. The purpose of the combined 
survey and administrative record analyses was to ascertain 
how the chronic health and functional characteristics of 
community and institutional residents using Medicare- 
reimbursed services changed over the period and how 
those changes related to the use of each of seven 
categories of Medicare services. Over this period, a 
number of regulatory and legislative changes had been 
made in the Medicare system that altered the use of 
different services by persons with specific health and 
functional profiles. 

Status: The final report is included in the conference 
proceedings, Persons With Disabilities, and is available 
from the Brookings Institute. 

94-096 Project Demonstrating and Evaluating 
Alternative Methods to Assure and Enhance the 
Quality of Long-Term Care Services for Persons with 
Developmental Disabilities through Performance- 
Based Contracts with Service Providers 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-C-90443/5 

September 1 994-September 1997 

S 800,000 

Cooperative Agreement 

Elaine J. Timmer 

Minnesota Department of 

Human Services 

Health Care Administration 

444 Lafayette Road 

St. Paul, MN 55155-3853 

Samuel L. Brown 

Division of Aging and Disability 



Description: The purpose of this project is to determine 
whether and how well the implementation of new 



approaches to quality assurance, with outcome-based 
definitions and measures of quality, will replace the input 
and process measures of quality and, in the process, 
contribute to improving the quality of life of persons with 
developmental disabilities. The Minnesota Department of 
Human Services will seek Federal authority to waive 
necessary provisions of the intermediate care facilities for 
the mentally retarded (ICF-MR) regulations to permit 
alternative quality assurance mechanisms in selected 
demonstration, residential, and support service programs. 
The department will enter into performance-based 
contracts with counties and participating ICF-MR 
providers. These contracts will specify the amount and 
conditions of reimbursement, requirements for monitoring 
and evaluation, and expected client-based outcomes. 
These client-based outcomes will be determined by the 
client and by the legal representative, if any, and with the 
assistance of the county case manager and provider. Some 
desirable outcomes include enhancement of consumer 
choice and autonomy, employment, and integration into 
the community. Criteria for measuring participating 
agency achievement will be drawn from, but not limited 
to, the outcome standards developed by the National 
Accreditation Council on Services for Persons with 
Developmental Disabilities; the "values experiences" of 
Frameworks for Accomplishment; and the goals 
established in Personal Futures Plans, Essential Lifestyle, 
and Person-Centered planning. According to the proposed 
quality assurance framework, monitoring of individual 
outcomes will be done jointly among family members, 
case managers, and other members of the local review 
team on a quarterly basis. 

Status: The award was made to Minnesota Department of 
Human Services on September 30, 1994. The first year of 
the cooperative agreement was used to further develop the 
demonstration. In December 1995, the State was granted 
a section 1115 waiver to implement the demonstration. 

Significant progress has been made toward meeting the 
program objectives. During the first operational year the 
following goals were achieved: 

• The establishment of baseline data on outcome 
indicators to be used for the purpose of establishing 
performance target for the second operational year. 

• The development of Quality Enhancement Teams to 
conduct the annual performance reviews. These teams 
are comprised of consumers, advocates, volunteers, and 
state staff. 

• Training and technical assistance was provided to all 
parties involved in the project's implementation to 
ensure that they could successfully fulfill their roles in 
the new outcomes-based ICF/MR service delivery 
system. 

• The first phase of the qualitative/case study review of 
the project's implementation was completed. 



160 



Theme 3: Meeting the Needs of Vulnerable Populations 



Several approaches have been taken to develop alternative 
means of ensuring that quality services are provided. 
Providers were granted variances to existing State 
licensing rules governing ICFs-MR, waivered services, 
semi-independent living services and day training and 
habilitation services; waiver to parts of the rule licensing 
supervised living facilities; and changes to the statute 
governing case management through an established 
reform process. 

The University of Minnesota is under contract with the 
State to provide project participants with technical 
assistance and training in personal futures planning, self 
determination and organizational management and 
change. 

Minnesota's Department of Human Services entered into 
a 3-year contract with the University of Minnesota 
Institute on Community Integration for the evaluation of 
the performance-based contracting demonstration project. 
It is central to this demonstration and its evaluation to be 
able to establish that the alternative quality assurance 
approaches improve or at least do not decrease the quality 
of life and services for the persons involved. This 
evaluation will include both process and outcome 
components. The process evaluation will describe and 
evaluate the procedures and activities undertaken to 
develop alternative outcome-based quality assurance 
programs. The process evaluation is by it nature 
qualitative, relying heavily on interviews with key people 
in the process of developing, implementing and otherwise 
being affected by the approaches being developed. Other 
qualitative data collection will include on-site direct 
observation and document review. 

The outcome evaluation component of the demonstration 
is primarily a quantitative data collection activity seeking 
to obtain objective quantifiable measures of the products 
of the programs and services under the alternative 
assurance programs. Quantitative measures will include 
frequencies of different types of activities, access to, 
utilization and satisfaction with the services provided, 
ratings of changes in the content, quality and person- 
centeredness of service plans, nature and frequency of 
social relationships and so forth. Process and outcome 
evaluation components will be examined independently in 
descriptive analyses, but also inferentially to determine if 
any process variables (independent) may be associated 
with outcomes (dependent variables). A control condition 
will also be established. A matched group sample for 
comparison of demonstration and non-demonstration 
group outcomes will be drawn from Minnesota samples 
currently participating in the Minnesota Longitudinal 
Study and the 1992 participants in the independent 
assessment of Minnesota's Medicaid Home and 
Community Based Services waiver program. 



94-131 Randomized Controlled Trial of 
Primary and Consumer-Directed Care for 
Persons with Chronic Illnesses 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



95-C-90467/2 

September 1 994-September 1997 

$ 345,243 

Cooperative Agreement 

Gerald Eggert, Ph.D. 

Monroe County Long Term Care 

Program, Inc. 

349 West Commercial Street, Suite 2250 

Piano Works 

East Rochester, NY 14445 

Carolyn Rimes 

Division of Aging and Disability 



Description: This demonstration will assess differences in 
outcome for three treatment groups: a consumer-directed 
group, a case-managed service group, and a model that 
combines both treatment patterns. Findings will be 
compared with a control group that receives no additional 
services or benefits. Eligibility for participation is 
determined by residence in the community (at home or in 
an assisted living setting) and by Medicare coverage with 
a diagnosis of irreversible dementia or three or more 
limitations in activities of daily living. In addition, 
participants must be at risk for hospitalization (i.e., their 
participation is based on prior use of hospitals or 
emergency rooms). 

Status: This project has completed the developmental 
phase. A waiver package has been prepared and this is 
under review. Implementation is anticipated in 
December 1996. 

93-035 Rehabilitating Medicare Beneficiaries at Home 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



95-C-90243/1 

April 1993-April 1994 

$ 80,000 

Cooperative Agreement 

Samuel Scialabba 

Wellmark Healthcare Services, Inc. 

60 William Street 

Wellesley, MA 02181 

Stefan N. Miller 

Division of Aging and Disability 



Description: Wellmark intends to conduct a 2-year 
Medicare demonstration that will provide beneficiaries 
with acute rehabilitation services at home as an 
alternative to more expensive inpatient rehabilitation 
hospital services. The Health Care Financing 
Administration has awarded a cooperative agreement to 



Theme 3: Meeting the Needs of Vulnerable Populations 



161 



Wellmark to further refine its project design to develop 
information on specific eligibility and screening criteria 
for patient enrollment, detailed cost data on the proposed 
service package, and informed consent policies to 
adequately inform patients and caregivers of the risks and 
responsibilities of rehabilitative home care. Medicare 
waivers will be required to allow Wellmark reimburse- 
ment as a prospective payment, system-exempt 
rehabilitation hospital. Funding for the evaluation will be 
provided by the Robert Wood Johnson Foundation as part 
of a national study, "Evaluation of Innovative 
Rehabilitation Alternatives and Critical Dimensions of 
Rehabilitative Care." 

Status: The final report has been submitted. A request for 
Medicare waivers to implement the project was 
withdrawn by the Agency in May 1995. 

95-067 Rhode Island Long-Term Care Waiver: 
CHOICES 



Project No.: 


18-P-90655/1-01 


Period: 


May 1995-July 1996 


Funding: 


S 150,000 


Award: 


Grant 


Principal 




Investigator: 


Christine C. Ferguson 


Awardee: 


Rhode Island Department of 




Human Services 




600 New London Avenue 




Cranston, RI 02920 


HCFA Project 


Thomas Theis 


Officer: 


Division of Aging and Disability 



Mandate: 



Title XIX. Section 1115 



Description: In 1994, the State of Rhode Island 
Department of Human Services (DHS) and Department of 
Mental Health, Retardation and Hospitals (MHRH) 
submitted a waiver-only proposal which intends to 
consolidate all current State and Federal funding streams 
for approximately 4,000 adults with developmental 
disabilities under one managed care Title XIX waiver 
program. The State proposed a 5-year demonstration with 
a two-phase transition process. The State wants to 
consolidate into a single program with a single set of rules 
the following separate Title XIX programs: 

• Intermediate care facilities for the mentally retarded 
(ICF-MR). 

• Home and community-based waiver. 

• State plan rehabilitation services. 

• Acute/medical care. 

Rhode Island envisions a publicly administered managed- 
care system with a single-payer model. Each eligible 
person will be enrolled in a private health maintenance 
organization or approved health plan for acute health care. 



Managed-care plans participating in Rhode Island's Rite 
Care program may be asked to participate in the 
CHOICES program and provide managed health care for 
people with developmental disabilities, thus bringing 
together Rhode Island's two managed-care initiatives. 
Alternatively, a statewide health care plan will be 
established for adults with developmental disabilities and 
the employees of the service agencies. 

Under CHOICES, a case-management system will also be 
available to assist each eligible individual to obtain 
required long-term supports. The State intends to ascribe 
to all eligible persons a dollar amount with which they, 
with technical assistance from a broker or other source, 
will choose to manage the long-term-care services directly 
themselves via a voucher, or choose an agency that can 
support their needs within the identified resources 
available. This dollar amount will be based on a 
methodology prepared by the assessment/authorization 
work group. 

Services covered by CHOICES can be divided into several 
categories: 

• Supported living services. 

• Alternative living arrangements. 

• Day supports. 

• Acute care/medical services. 

The covered target population under CHOICES consists 
principally of persons with MR or related conditions, and 
the developmentally disabled, who are already eligible for 
and receiving services under various currently operating 
Title XIX programs. 

In addition to its current population, CHOICES will serve 
up to 25 individuals with traumatic brain injury who are 
in need of long-term community living supports and who 
may be inappropriately institutionalized or living in the 
community with inadequate support; approximately 
500 individuals now receiving supported employment 
services funded with State monies; about 40 people 
currently in the State-funded developmental disabilities 
program for whom there is no Federal financial 
participation; and approximately 125 people turning 
21 and graduating from special education, applying for 
services from the Division of Developmental Disabilities 
under the Department of Human Services for Rhode 
Island. 

Status: The State was awarded a grant in June 1995 to 
further develop the project design. Waivers have not yet 
been awarded. 

94-104 Rhode Island Rite Care 

Project No.: I l-W-00004/1 

Period: August 1994-JuIy 1999 



\r>: 



Theme 3: Meeting the Needs of Vulnerable Populations 



Award: 
Principal 
Investigator: 
Awardee: 



HCFA Project 
Officer: 



Waiver-only Project 

Christine C. Ferguson 
State of Rhode Island 
Department of Human Services 
600 New London Avenue 
Cranston, RI 02920 
Deborah C. Van Hoven 
Office of State Health Reform 
Demonstrations 



Description: This statewide initiative, approved in 
November 1993, seeks to increase access to and delivery 
of primary and preventive health care services for all Aid 
to Families with Dependent Children recipients (65,000) 
and to extend coverage to approximately 4,000 pregnant 
women and children under 8 years of age, with family 
incomes up to 250 percent of the Federal poverty level 
(FPL). RIteCare eligibles will be required to enroll in 
prepaid health plans contracted with the State to provide 
comprehensive health services. Prepaid health plans will 
offer medical and mental health benefits. Long-term-care 
services will not be provided through the plans. Plans will 
be required to offer participants a package of enhanced 
services to assist in overcoming the non-financial barriers 
to care, including home visits, nutrition counseling, 
childbirth education, parenting skills education, and 
smoking cessation. Pregnant women enrolled in RIteCare 
who lose eligibility 60 days post-partum will be offered 
the opportunity to enroll in an extended family-planning 
program for a 2-year period. RIteCare will include a cost- 
sharing component. Individuals with incomes of between 
185 and 250 percent of the FPL (new eligibles) will be 
subject to cost-sharing requirements, either through 
premiums or copayment arrangements. Individuals with 
incomes of less than 185 percent of the FPL will not be 
subject to any cost-sharing requirements. 

Status: Enrollment in this program began August 1, 1994. 
As of June 1996, 70,015 currently eligible women and 
children had been enrolled in managed-care plans and 
1,352 pregnant women and children for whom eligibility 
has been extended. In addition, 1,072 clients were 
receiving extended family-planning benefits after having 
received the comprehensive benefit package until 60 days 
post-partum. 

94-124 Risk Adjustment of Payment for 
Mental Health and Substance Abuse 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 



18-C-90314/1 

October 1994-January 1997 
$ 1,056,690 
Cooperative Agreement 

Richard G. Frank, Ph.D. 



Awardee: 



HCFA Project 
Officer: 



Harvard Medical School 

25 Shattuck Street 

Boston, MA 02115 

Jay Bae, Ph.D. 

Division of Payment Systems 



Description: This risk-adjustment research project 
attempts to study the issues that arise from providing 
mental health and substance abuse care coverage under a 
capitation system. There are three main objectives of this 
project. One objective is to test the ability of three risk 
classification systems — ambulatory care groups (ACGs), 
diagnostic cost groups, and payment amount for capitated 
systems to explain variation in mental health and 
substance abuse (MH/SA) costs. The project will modify 
the existing systems to improve their ability to explain the 
variation in MH/SA costs. Another objective is to collect 
information on private-sector cost-sharing arrangements 
for "carve-out" providers of MH/SA benefits. Using the 
information, profits and losses of different arrangements 
will be compared. The third objective is to develop a 
simulation model that is based on the risk-classification 
systems and the private-sector cost-sharing arrangements. 
The project will evaluate the predictive accuracy of the 
hybrid simulation model for premium-setting purposes. 

Status:The project has completed its data analyses using 
the New Hampshire Medicaid programs. Private 
insurance data from the William Mercer Company have 
also been used to test the performance of alternative risk 
adjustment systems, e.g., the ACG and the DCG-HCC 
classification systems. Early results indicate that a 
modified ambulatory diagnostic group and a comorbidity 
model performed better, but none of the standard risk- 
adjustment models achieved R 2 values above 0.10. Hence, 
systematic selection remains a potential problem in a 
capitated mental health care program. 

Apart from the data analyses, two theoretical papers were 
recently produced. One paper written by McGuire and 
Glazer deals with the concept of optimal risk adjustment 
that takes into account the degree of asymmetric 
information in the market. Another paper written by 
Frank, McGuire, et. al. discusses the rationale for carve- 
outs in MH/SA care. Both papers are being reviewed for 
publication considerations. In addition, this project has 
produced two descriptive papers that report the latest 
developments in financial risk-sharing arrangements and 
specific quality standards, such as access, customer 
service, satisfaction, staffing requirements, etc., for 
MH/SA care in the managed behavioral health care 
industry. 

94-121 Rural Health Care 
Transition Grant Evaluation 

Project Nos.: 500-91-0075, 500-94-0011, 
500-95-0032 



Theme 3: Meeting the Needs of Vulnerable Populations 



163 



Period: 

Funding: 

Award: 

Principal 

Investigators: 



Awardee: 



HCFA Project 
Officer: 



Mandates: 



October 1991 
S 2,619,225 
Contract 



-February 1999 



Craig Thornton, Ph.D., 
Valerie Cheh, Ph.D., and 
Jeanette Bergeron 
Mathematica Policy Research, Inc. 
P. O. Box 2393 
Princeton, NJ 08543-2393 
Siddhartha Mazumdar, Ph.D. 
Division of Delivery Systems and 
Financing 

Omnibus Budget Reconciliation Act of 
1987 (Public Law 100-203) Omnibus 
Budget Reconciliation Act of 1989 
(Public Law 101-239) 



Description: Mathematica Policy Research, Inc. (MPR) 
has completed its monitoring of the fiscal years 1989, 
1990, 1991, and 1992 grantees and is performing post- 
award functions for fiscal years 1992, 1993, 1994, 1995, 
and 1996 Rural Health Care Transition grantees, which 
include: 

• Monitoring grantees to determine how grant funds are 
being spent. 

• Maintaining an ongoing profile of the grantees' 
progress in planning and/or implementing the 
components of their programs. 

• Reporting to the Health Care Financing Administration 
the results of the monitoring, the perceived needs of 
rural hospitals, and the evaluation of the projects and of 
the impact and effectiveness of the program. 

These contracts individually focus on the monitoring and 
evaluation of the yearly grantee cohorts. With the 
exception of Connecticut, Delaware, Massachusetts, New 
Jersey, and Rhode Island, all States participated in the 
rural health transition program. In accordance with the 
recent change of the authorizing legislation, MPR is 
currently producing annual reports on the grant program 
for submission to Congress. These reports present general 
status descriptions on the progress of the grantees, 
including what services they are providing with grant 
funds. In addition, the reports focus on special topics 
pertaining to the grantee hospitals and rural health issues 
in general (e.g., how hospitals in low-income areas 
survive financially and the contribution of mid-level 
practitioners to small rural hospitals). 

Consistent findings from the MPR evaluation include: 

• Local access to specific services has increased inasmuch 
as grant funding has produced a variety of new services 
that patients are using; however, overall utilization and 
services have been unaffected by the grant program. 



• Problems have persisted in recruiting and retaining 
physicians. 

• The closure rate for grantee hospitals is equivalent to 
the closure rate for small rural hospitals nationwide; the 
grant program generally has failed to produce 
consolidation and conversion among hospitals. 

89-029 Rural Health Care Transition Grants Program 



Period: 
Funding: 
Award: 
HCFA Project 
Officer: 



Mandates: 



September 1989-September 1997 

$ 13.8 million 

Grants 

William L. Damrosch 

Division of Delivery Systems and 

Financing 

Omnibus Budget Reconciliation Act of 
1987 (Public Law 100-203, amended by 
Section 6003(g)(1)(B) of the Omnibus 
Budget Reconciliation Act of 1989, 
Public Law 101-239) 



Description: Congress appropriated $13.8 million in fiscal 
year (FY) 1996 to fund the Rural Health Care Transition 
Grants program. Funding for FY 1996 provided grants for 
new awards in 1996, second-year funding for projects 
awarded in FY 1995, and third-year funding for projects 
awarded in 1994, as well as an independent evaluation. 
These grants will support a variety of innovative projects 
to strengthen the capability of small rural hospitals and 
their communities to provide high-quality care to 
Medicare beneficiaries. Under this grants program, 
eligible rural hospitals may request up to $50,000 per year 
for up to 3 years. Hospitals receiving awards requested 
funds to support activities in such areas as enhancing 
outpatient and/or emergency services, recruiting health 
professionals, and developing alternative service delivery 
systems (including rural health care networks) to provide 
care more effectively. Hospitals qualified for this program 
if they were non-Federal, not-for-profit, short-term, 
general acute-care hospitals located in rural areas (i.e., 
those currently being paid as rural hospitals under the 
Medicare hospital prospective payment system) and had 
fewer than 100 available beds (as defined in the Medicare 
Cost Report). 

Status: On September 30, 1996, the Office of Research 
and Demonstrations within the Health Care Financing 
Administration (HCFA) made 1 10 new awards from 270 
applications received. Each application was reviewed for 
technical merit by a panel of experts. Of the 1 10 awards 
in FY 1996, 65 went to hospitals applying as individual 
facilities and 45 went to hospitals applying as part of a 
consortium (9 consortia). Of the grants awarded to 
hospitals in FY 1995 and FY 1994, 187 hospitals 
requested and received second-year and third-year 
continuation funding totaling $8.2 million. HCFA 



IM 



Theme 3: Meeting the Needs of Vulnerable Populations 



continues to contract with Mathematica Policy Research, 
Inc., to evaluate the program and to provide technical 
support in monitoring the program. 

84-004 Social Health Maintenance Organization 
Project for Long-Term Care: Elderplan, Inc. 

(Formerly, Social Health Maintenance Organization 
Project for Long-Term Care) 

Project No.: 95-P-09 101/2 

Period: August 1984-December 1997 

Funding: Waiver only Project 

Award: Grant 

Principal 

Investigator: Eli Feldman 

Awardee: Elderplan, Inc. 

6323 Seventh Avenue 

Brooklyn, NY 11220 
HCFA Project Thomas Theis 
Officer: Division of Aging and Disability 

Mandates: Deficit Reduction Act of 1984 

(Public Law 98-369) 
Omnibus Budget Reconciliation Act of 
1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 
Omnibus Budget Reconciliation Act of 
1993 (Public Law 103-66) 

Description: In accordance with section 2355 of Public 
Law 98-369, this project was developed to implement the 
concept of a social health maintenance organization 
(S/HMO) for acute and long-term care. S/HMO integrates 
health and social services under the direct financial 
management of the provider of services. All services are 
provided by or through the S/HMO at a fixed, annual, 
prepaid capitation sum. Four demonstration sites were 
selected to participate. Of the four sites, two were health 
maintenance organizations that have added long-term- 
care services to their existing service packages and two 
were long-term-care providers that have added acute-care 
service packages. Elderplan is one of the long-term-care 
provider sites that developed and added an acute-care 
ser\'ice component. HealthPartners (formerly Group 
Health in Minneapolis-St. Paul, Minnesota), one of the 
original sites, discontinued participation on 
January 1, 1995. 

Status: Elderplan implemented its service delivery 
network in March 1985. Elderplan uses both Medicare 
and Medicaid waivers. During the first 30 months of 
operation, Federal and State Governments shared 
financial risk with the sites. This risk sharing ended 
August 31, 1987. On three separate occasions, this 
demonstration has been extended by legislation. Current 
legislation, Public Law 103-66, extends the demonstration 
period through December 31, 1997. 



84-006 Social Health Maintenance Organization 
Project for Long-Term Care: Kaiser Permanente 
Center for Health Research (Formerly, Social Health 
Maintenance Organization Project for Long-Term Care) 

Project No.: 95-P-09103/0 

Period: August 1984-December 1997 

Funding: Waiver only Project 

Award: Grant 

Principal 

Investigator: Lucy Nonnenkamp 

Awardee: Kaiser Permanente Center for 

Health Research 
3800 North Kaiser Center Drive 
Portland, OR 97227-1098 

HCFA Project Thomas Theis 

Officer: Division of Aging and Disability 

Mandates: Deficit Reduction Act of 1984 

(Public Law 98-369) 
Omnibus Budget Reconciliation Act of 
1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 
Omnibus Budget Reconciliation Act of 
1993 (Public Law 103-66) 

Description: In accordance with section 2355 of Public 
Law 98-369, this project was developed to implement the 
concept of a social health maintenance organization 
(S/HMO) for acute and long-term care. A S/HMO 
integrates health and social services under the direct 
financial management of the provider of services. All 
services are provided by or through the S/HMO at a fixed, 
annual, prepaid capitation sum. Four sites were selected to 
participate; of the four, two were health maintenance 
organizations (HMOs) that have added long-term-care 
services to their existing service packages and two were 
long-term-care providers that have added acute-care 
service packages. Kaiser Permanente Center for Health 
Research (doing business as Medicare Plus II) is one of 
the HMO sites that developed and added a long-term-care 
component to its service package. HealthPartners 
(formerly Group Health in Minneapolis-St. Paul, 
Minnesota), one of the original sites, discontinued 
participation on January 1, 1995. 

Status: Medicare Plus II implemented its service delivery 
network in March 1985. Medicare Plus II uses Medicare 
waivers only. During the first 30 months of operation, the 
Federal Government shared financial risk with the 
Oregon site. This risk sharing ended August 31, 1987. On 
three separate occasions, this demonstration has been 
extended by legislation. Current legislation, Public Law 
103-66, extends the demonstration period through 
December 31, 1997. 



Theme 3: Meeting the Needs of Vulnerable Populations 



165 



84-007 Social Health Maintenance Organization 
Project for Long-Term Care: SCAN Health Plan 

(Formerly. Social Health Maintenance Organization 
Project for Long-Term Care) 

Project No.: 95-P-09 104/9 

Period: August 1 984-December 1997 

Funding: Waiver only Project 

Award: Grant 

Principal 

Investigator: Sam Ervin 

Awardee: SCAN Health Plan 

3780 Kilroy Airport Way, Suite 600 

P. O. Box 22616 

Long Beach, CA 90801-5616 

HCFA Project Thomas Theis 

Officer: Division of Aging and Disability 

Mandates: Deficit Reduction Act of 1984 

(Public Law 98-369) 
Omnibus Budget Reconciliation Act of 
1987 (Public Law 100-203) 
Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 
Omnibus Budget Reconciliation Act of 
1993 (Public Law 103-66) 

Description: In accordance with section 2355 of Public 
Law 98-369, this project was developed to implement the 
concept of a social health maintenance organization 
(S/HMO) for acute and long-term care. S/HMO integrates 
health and social services under the direct financial 
management of the provider of services. All services are 
provided by or through the S/HMO at a fixed, annual, 
prepaid capitation sum. Four sites were selected to 
participate; of the four, two were health maintenance 
organizations that have added long-term-care services to 
their existing service packages and two were long-term- 
care providers that have added acute-care service 
packages. SCAN Health Plan is one of the long-term-care 
provider sites that developed and added an acute care 
service component. HealthPartners (formerly Group 
Health in Minneapolis-St. Paul, Minnesota), one of the 
original sites, discontinued participation on 
January 1, 1995. 

Status: SCAN Health Plan implemented its service 
delivery network in March 1985. SCAN Health Plan 
utilizes both Medicare and Medicaid waivers. During the 
first 30 months of operation, Federal and State 
Governments shared financial risk with the sites. This 
risk sharing ended August 31, 1987. On three separate 
occasions, this demonstration has been extended by 
legislation. Current legislation, Public Law 103-66, 
extends the demonstration period through 
December 31, 1997. 



95-022 South Carolina Palmetto Health Initiative 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-D-00027/4 

November 1 994-November 1996 

Waiver-only Project 

Eugene A. Laurent, Ph.D. 

South Carolina Health and 

Human Services 

Finance Commission 

P. O. Box 8206 

Columbia, SC 29202 

Sherrie L. Fried 

Office of State Health Reform 

Demonstrations 



Description: The Palmetto Health Initiative (PHI) would 
extend health care coverage to approximately 280,000 
South Carolinians by expanding eligibility guidelines to 
those residents at or under 100 percent of the Federal 
poverty level. The PHI would require that each member 
select either a fully capitated managed health plan or a 
partially capitated primary physician plan, thus giving 
them direct access to a primary care provider. PHI would 
enable South Carolina to streamline the eligibility process 
and reduce administrative overhead while providing better 
access to primary and preventive care. In addition, South 
Carolina proposed a 500-member pilot project to 
demonstrate that the total health care service needs of the 
population traditionally deemed to require, or to be at risk 
for, placement in a nursing facility can be effectively met 
at a lower cost through a managed-care system that 
emphasizes home and community-based services. 

Status: The State has indefinitely postponed proceeding 
with the development phase of the project. 

96-063 South Carolina Welfare Reform: 
Family Independence Act 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00081/4 

June 1996-May2003 

Waiver-only Project 

Gwen Power 

South Carolina Department of Health 

and Human Services 

P. O. Box 8206 

Columbia, SC 29202-8206 

Joan Peterson, Ph.D. 

Office of State Health Reform 

Demonstrations 



Description: This project limits Aid to Families with 
Dependent Children (AFDC) cash benefits to families 
with able-bodied adults to 24 months; allows relocation, 
under certain criteria, for a family to receive a good-cause 



166 



Theme 3: Meeting the Needs of Vulnerable Populations 



extension of AFDC cash benefits; requires applicants and 
recipients to sign Individual Self-Sufficiency Plans 
(ISSPs) outlining employment and training requirements 
and family skills training; allows random testing in 
conjunction with substance abuse treatment; imposes 
progressive fiscal sanctions which may result in a full- 
family sanction for failure to comply with the ISSP; 
requires up-front job search as a condition of eligibility 
and requires job-ready individuals to participate in 
alternate work experience; imposes a family cap, but 
provides benefits to affected children in the form of 
vouchers/commodities; eliminates principal earner 
provisions, work history requirements, and the 100-hour 
rule for AFDC-Unemployed Parent cases. The Family 
Independence Act also provides transitional child care 
and transitional Medicaid for up to 24 months and 
without regard to prior AFDC receipt. Medicaid eligibility 
is continued for individuals for up to 90 days after 
termination of AFDC benefits due to the removal of 
dependent child(ren) from the home because of abuse or 
neglect if the individual is participating in substance 
abuse treatment. 

Status: This project is in the early implementation stage. 
With the August 22, 1996 enactment of the Personal 
Responsibility and Work Opportunity Reconciliation Act 
of 1996 (PRWORA), it is anticipated that the Title IV-A 
component of this demonstration will be modified. 
However, the impact of the PRWORA is being analyzed. 

92-026 Special Care Managed Care Initiative 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-C-90 127/5 

February 1992-December 1996 

$ 656,270 

Cooperative Agreement 

Howard Garber, Ph.D. 

Wisconsin State Department of 

Health and Social Services 

1 West Wilson Street 

P. O. Box 309 

Madison, WI 53701-0309 

Samuel L. Brown 

Division of Aging and Disability 



Description: The purpose of the special care initiative 
project is to gain improved understanding of the need, 
use, and cost of delivery of health services to high-risk, 
severely disabled persons. The severely disabled 
population is a significant user of medical services. 
Moreover, cost between 1988 and 1991 increased at a rate 
double that of population increase. Therefore, an 
important objective is to contain the cost and use of 
Medicaid services by severely disabled persons, while 
maintaining or improving the level of client satisfaction. 



Special Care, Inc. (SCI) is an independent, nonprofit 
organization that represents a joint venture between the 
Milwaukee Center for Independence, a Milwaukee 
rehabilitation facility, and the Wisconsin Health 
Organization, an established health maintenance 
organization. SCI will create specialized services, 
including a dedicated physician panel, case-management 
services, and clinical services as strategies to assess 
medical need and to better coordinate service resources 
available in the community. The State of Wisconsin will 
use a capitation methodology for reimbursement to SCI. 
Enrollment of SCI members will be voluntary. 

As a research and demonstration program, it aims to 
improve the understanding of the need, use, costs, and 
cost-management opportunities associated with the 
delivery of health services to high-risk, severely disabled 
persons. These individuals are disabled, categorically 
needy, noninstitutionalized, exempt from the spenddown 
provisions, eligible for Medicaid, and eligible for 
Supplemental Security Income disability benefits. The 
diagnostic distribution of cases in this population is 
41 percent mental retardation, 17.4 percent chronic 
mental illness, 13.5 percent skeletal/muscular, 
1 1.2 percent epilepsy, 9.3 percent cerebral palsy, 
1.6 percent cardiac/circulatory, 1.2 percent autism, and 
4.9 percent other. This is a severely disabled and 
generally unemployable population whose medical care 
use and cost experience show a non-normalized pattern. 
The average hospital length of stay for members of this 
group is 7 times longer than that for the general 
population. Their hospital costs are 4 times higher- 
without clear explanation. 

To measure the performance of the SCI program, a 
management information system (MIS) file will be 
created to match the demographic characteristics of 
program participants with the cost and use data obtained 
from the history files maintained by the Wisconsin 
Medicaid program. Medicaid data will include service and 
procedure frequencies, service mix, billings and 
reimbursements, provider practices, and certain medical 
status indicators. MIS files will contribute additional 
information on disability condition, enrollment 
information, benefit coordination, and case management. 
In addition, data on client satisfaction, quality of care, 
and enrollment/disenrollment decisions will be collected. 

Status: The State is operating this project under a section 
1915(a) State Plan exception. The program officially 
began in June 1994. As a point of clarification, Special 
Care signifies the initiative proposed to the Health Care 
Financing Administration (HCFA) for the managed-care 
program, while Independent Care (I Care) is the formal 
community name of the managed-care company. In July 
1996, a no-cost extension was granted to the State to 
allow for a full 3-year operational period. 



Theme 3: Meeting the Needs of Vulnerable Populations 



167 



The evaluation contract with the Human Services 
Research Institute (HSRI) was signed in May 1994, after 
it was reviewed and approved by HCFA. This evaluation 
contractor submitted its final working plan at the 
beginning of grant Year 03. HSRI proposes a 3-year 
evaluation, which will combine survey data with HCFA's 
Medicaid Statistical Infonnation System Administrative 
files. 

The evaluator developed and piloted an interview 
protocol, the Cross-Disability Integrated Health Outcomes 
Survey for use with the I Care recipients and control 
group members. Evaluation activities will include the 
selection of comparison groups, using cost cluster 
information from a State-developed profile of a sample of 
I Care patients. This sample was drawn from an aggregate 
of all 1994 paid claims for every Milwaukee and Racine 
county Supplemental Security Income beneficiary who is 
disabled and was then assigned to one of three cost 
categories — low, medium, or high. Interim evaluation 
findings are expected in December 1996. 

91-016 Staff-Assisted Home Dialysis Demonstration 



Project No.: 
Period: 
Funding: 
Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandate: 



500-87-0030TO09 

June 1991-December 1995 

$ 914,203 

Technical Support: Evaluation of 

Demonstrations 

Andrea Hassol 

Abt Associates, Inc. 

55 Wheeler Street 

Cambridge, MA 02138-1168 

Bonnie M. Edington 

Division of Health Infonnation and 

Outcomes 

Omnibus Budget Reconciliation Act of 
1990 (Public Law 101-508) 



Description: The purpose of this demonstration was to test 
whether providing Medicare-paid home hemodialysis 
assistants for end stage renal disease (ESRD) patients 
meeting stringent eligibility criteria (e.g., bed- or 
wheelchair-bound) is cost effective, in that it reduces 
Medicare-covered ambulance costs for transporting 
patients to maintenance dialysis in facilities or reduces 
hospital admissions attributed to transportation-related 
problems. The legislation limits the experimental benefit 
to a maximum of 800 patients and stipulates a detailed 
ratesetting formula. 

Findings: 

Extensive outreach efforts were undertaken, however, 
only 91 patients were enrolled in the demonstration. The 
eligibility criteria tended to characterize patients too ill 



for home hemodialysis. Although 46 patients had been 
randomly assigned to the experimental group, 10 were 
withdrawn from the demonstration and 1 2 died before 
they could receive the experimental service. The overall 
mortality rate among all enrollees was 78 percent over a 
period of 2 years and 9 months, in contrast to a 44- 
percent rate among the general ESRD population. Since 
the demonstration did not have a sufficient number of 
patients for meaningful statistical analysis, a series of 
related research studies was undertaken: comparing and 
contrasting demonstration enrollees with ambulance- 
using ESRD patients not enrolled in the demonstration; 
identifying detailed characteristics of ESRD ambulance 
users; assessing reasons for and alternatives to ambulance 
transport to dialysis; comparing and contrasting ESRD 
nursing home residents with other ESRD patients; and 
analyzing the components of cost for high-cost ESRD 
patients. 

Status: An interim report was submitted to Congress in 
January 1993. The final report is under review. 

94-123 State-Administered Programs for Human 
Immunodeficiency Virus-Related Care 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-P-90286/5 

September 1994-August 1996 

$56,133 

Grant 

Robert J. Buchanan, Ph.D. 

Board of Trustees of the 

University of Illinois 

Department of Community Health 

109 Coble Hall 

801 South Wright Street 

Champaign, IL 61820 

Michael Kendix, Ph.D. 

Division of Health Information and 

Outcomes 



Description: The study describes, catalogues, and analyzes 
a range of State-administered public programs that cover 
and finance the health care needs of persons with 
acquired immunodeficiency syndrome (AIDS) and 
persons who are infected with the human 
immunodeficiency virus (HIV). The study focuses on 
Title II programs of the Ryan White CARE Act; State- 
funded medical assistance programs; and Medicaid 2176 
home and community-based waivers. It also focuses on 
the action of the States' health departments that address 
the increasing incidence of tuberculosis, especially among 
persons with AIDS and people who are HIV-positive, and 
the coordination of eligibility for these State-administered 
programs with the Medicaid program of each State. This 
project also investigates the assessments the 
administrators of each State's AIDS office ( as well as the 



H.X 



Theme 3: Meeting the Needs of Vulnerable Populations 



administrators of voluntary AIDS organizations at the 
State and local levels) have about how well each of these 
State-administered programs (including Medicaid) 
addresses the health care needs of people with AIDS and 
people infected with HIV, closing any holes in the 
Medicaid safety net. 

Status: This project is almost complete. The project has 
generated a number of papers that have been accepted for 
peer review. 

95-020 State Health Care Reform Monitoring 



Description: The purpose of this project is to assist States 
in implementing section 1115 health care reform 
demonstrations and to assist the Health Care Financing 
Administration (HCFA) in monitoring quality of care in 
these demonstrations. The MedStat Group will develop 
three guides: the first for use by States as they develop 
and implement encounter data systems, the second for the 
use of HCFA's Regional Offices (ROs) in monitoring the 
quality of care in Medicaid managed care, and the third 
for use by ROs in monitoring encounter data 
implementation by the States. 

Additionally, MedStat will provide direct technical 
assistance to States on encounter data and quality 
assurance issues. MedStat will also provide training 
sessions on related topics to the ROs in year two of the 
project. 

Status: The contract was awarded on September 30, 1995. 
Medstat has developed two guides so far under the terms 
of this contract: the first for use by States as they develop 
and implement encounter data systems, and the second for 
the use of HCFA's ROs in monitoring and quality of care 
in the demonstrations. An additional guide will be 
completed for use by HCFA's ROs in monitoring 
encounter data implementation by the States. Thus far, 
Medstat has provided assistance to seven States 
(Delaware, Hawaii, Illinois, Minnesota, Oklahoma, 



Tennessee, and Vermont) on a wide variety of topics. RO 
training has also begun and will continue throughout 
fiscal year 1997. 

95-089 State of Minnesota "Senior 
Health Options (SHO) Project" 



Project No. 
Period: 

Funding: 

Award: 

Principal 



Project No.: 


500-92-0035/DO03 


Investigator: 


Period: 


September 1 995-September 1998 


Awardee: 


Funding: 


$ 1,464,511 




Award: 


Delivery Order in Master Contract 
(See page 132) 




Principal 






Investigator: 


Patrice Wolfe 


HCFA Project 


Awardee: 


MedStat Group 

4401 Connecticut Ave., NW., Suite 400 


Officer: 




Washington, DC 20008 


Mandates: 


Project 


Kathy Rama 




Officer: 


Office of State Health Reform 
Demonstrations 





ll-W-00024/5 

April 1995-December2000 

(yearly continuation) 

Waiver-only Project 

Grant 

Pamela Parker 

Minnesota Department of 

Human Services 

Human Services Building 

444 Lafayette Road 

St. Paul, MN 55155 

Melissa Hulbert, MPS 

Division of Aging and Disability 

Section 1115 of the Social Security Act 
and Section 402 of the 1967 
Amendments to the Social Security Act 



Description: In April 1995, the State of Minnesota was 
awarded Medicare and Medicaid waivers for a 5-year 
demonstration designed to test delivery systems that 
integrate long-term care and acute-care services for 
elderly dual eligibles. The State is targeting the elderly 
dually entitled population that resides in the 7-county 
metro area and St. Louis county. Elderly Medicaid 
eligibles now required to enroll in the State's current 
section 1115 Prepaid Medical Assistance Program 
(PMAP) demonstration will be given the option to enroll 
in the Senior Health Options (SHO) Project, which in 
essence adds long-term care and Medicare benefits to 
basic PMAP benefits. Under this demonstration, the State 
will be treated as a health plan that contracts with Health 
Care Financing Administration to provide services, and 
provides those services through subcontracts with various 
appropriate providers. The State will continue its current 
administration of the Medicaid managed-care program 
while incorporating some Medicare requirements that 
apply directly to the health plans with which the State 
would subcontract for SHO. HCFA's direct oversight 
functions would continue to apply to the overall 
demonstration and managing entity, which would be 
the State. 

Status: The State intends to implement the project 
January 1, 1997. 



Theme 3: Meeting the Needs of Vulnerable Populations 



169 



92-102 State Response to Medicaid Estate Planning 

(Formerly, Long-Term Care Studies (Section 207)) 

Project No.: 500-89-0047/36 

Period: May 1992-May 1993 

Funding: S 41,000 

Award: Contract 

Principal 

Investigator: David Kennell 

Awardee: Lewin/VHI, Inc. 

(See page 17) 

HCFA Project Carolyn Rimes 

Officer: Division of Aging and Disability 

Description: The purpose of this report is to provide 
readers with an overview of recent State initiatives 
regarding Medicaid estate planning. Data for the report 
were collected primarily through telephone interviews 
with key personnel at Medicaid eligibility offices in 
26 States. In those States where initiatives were under 
way, copies of recent legislation, regulations, task force 
reports, internal memoranda, and other documents were 
obtained and reviewed. This project was completed by 
SysteMetrics/MedStat under subcontract to 
Lewin/VHI, Inc. 

Status: The study found that many States are attempting 
to place limitations on asset transfers in an effort to 
restrict Medicaid estate-planning practices. Furthermore, 
States have expressed a strong desire for Federal 
clarification on Medicaid transfer-of-asset provisions and 
want additional Federal legislation that further restricts 
the transfer of assets. 

94-030 State Rural Health Network Reform Initiative: 
Assisting Washington Rural Communities Transition 
to Health Care Reform 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



50-P-90262/0 

August 1994-April 1996 

$ 350,000 

Grant 

Alice James 

Washington State Department of Health 

Office of Community and Rural Health 

P. O. Box 47834 

Olympia, WA 98504-7834 

Sheldon Weisgrau 

Division of Delivery Systems and 

Financing 



Description: The State Rural Health Network Reform 
Initiative provided grant funds to States to develop 
innovations in rural health financing and delivery 
systems. The initiative was designed to enable States to 
address rural health issues within the context of 



comprehensive statewide and national health reform. 
Through a competitive process, a total of $1.7 million was 
awarded to the States of Florida, Minnesota, Mississippi, 
Nebraska, North Carolina, and Washington to support the 
planning, development, and implementation of new 
financing and delivery arrangements that enhance access 
to health care services and maintain a viable delivery 
system for rural residents. The initiative was originally 
designed as a 3-year project, scheduled to conclude in 
August 1997. Funding for the second year of the program, 
however, was rescinded by Congress and no additional 
funds were appropriated. Participating States closed out 
program operations in April 1996. 

Status: The main purpose of this project was to assist 
rural communities to develop integrated health delivery 
systems. The Washington State Office of Community and 
Rural Health provided support, technical assistance, and 
education to selected communities on health network 
organizational options, financing strategies, legal 
requirements, and implementing and operating managed- 
care systems. Organizations such as the Washington State 
University Cooperative Extension and the Washington 
State Grange were partners in these efforts. Physician- 
hospital organizations were formed in two rural 
communities and public health assessment tools 
developed in another. The Office of Community and 
Rural Health also contracted with the University of 
Washington Rural Health Research Center and the Health 
Policy Analysis Program to document changes occurring 
in rural community health systems in the State and to 
assemble baseline information on the expansion of 
managed care into rural counties. Two other activities 
initially included in this project, staffing for the 
Northwest Rural Health Association and the development 
of an American Indian Health Care Delivery Plan for the 
State, were funded by other sources. 

94-025 State Rural Health Network Reform Initiative: 
Financing Models for Florida's Rural Health Networks 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



50-P-90257/4 
August 1994-April 
$ 300,000 
Grant 



:996 



Wayne McDaniel 

Agency for Health Care Administration 

2727 Mahan Drive 

Tallahassee, FL 32308-5402 

Sheldon Weisgrau 

Division of Delivery Systems and 

Financing 



Description: The State Rural Health Network Reform 
Initiative provided grant funds to States to develop 
innovations in rural health financing and delivery 



70 



Theme 3: Meeting the Needs of Vulnerable Populations 



systems. The initiative was designed to enable States to 
address rural health issues within the context of 
comprehensive statewide and national health reform. 
Through a competitive process, a total of $1.7 million was 
awarded to the States of Florida, Minnesota, Mississippi, 
Nebraska, North Carolina, and Washington to support the 
planning, development, and implementation of new 
financing and delivery arrangements that enhance access 
to health care services and maintain a viable delivery 
system for rural residents. The initiative was originally 
designed as a 3-year project, scheduled to conclude in 
August 1997. Funding for the second year of the program, 
however, was rescinded by Congress and no additional 
funds were appropriated. Participating States closed out 
program operations in April 1996. 

Status: This project focused on developing integrated 
financing strategies for rural networks within the context 
of Florida's managed-competition health-care-reform 
efforts. Consistent with State legislation to promote the 
development of rural health networks, the Florida Agency 
for Health Care Administration (AHCA) assisted rural 
networks in investigating network financing strategies, 
developing infrastructure, and examining legal issues. 
Eight rural health networks received planning grants from 
the State, and two of these were awarded additional grants 
to develop network financing models. AHCA also used 
project resources to analyze funding for indigent care in a 
four-county area and design an evaluation of the State's 
program. 

94-026 State Rural Health Network Reform Initiative: 
Minnesota Rural Health Network Reform Initiative 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



50-P-90279/5 

August 1994-April 1996 

$ 325,000 

Grant 

Chari Konerza 

Minnesota Department of Health 

Office of Rural Health 

121 East Seventh Place 

P. O. Box 64975 

St. Paul, MN 55164-0975 

Sheldon Weisgrau 

Division of Delivery Systems and 

Financing 



Description: The State Rural Health Network Reform 
Initiative provided grant funds to States to develop 
innovations in rural health financing and delivery 
systems. The initiative was designed to enable States to 
address rural health issues within the context of 
comprehensive statewide and national health reform. 
Through a competitive process, a total of $1.7 million was 
awarded to the States of Florida, Minnesota, Mississippi, 



Nebraska, North Carolina, and Washington to support the 
planning, development, and implementation of new 
financing and delivery arrangements that enhance access 
to health care services and maintain a viable delivery 
system for rural residents. The initiative was originally 
designed as a 3-year project, scheduled to conclude in 
August 1997. Funding for the second year of the program, 
however, was rescinded by Congress and no additional 
funds were appropriated. Participating States closed out 
program operations in April 1996. 

Status: The goal of this project was to assist rural 
communities in building the infrastructure necessary for 
the development and implementation of rural health 
networks organized as Community Integrated Service 
Networks (CISNs) or Health Care Cooperatives as defined 
in Minnesota statute. The Minnesota Office of Rural 
Health implemented a technical assistance program for 
CISN and Health Care Cooperative development and 
awarded planning and implementation grants to six rural 
health networks. By the end of the program period, four 
CISNs and seven health care provider cooperatives had 
been organized in rural Minnesota, and other networks 
continue to emerge throughout the State. Net-TAP, the 
technical assistance program developed through this 
initiative, is in great demand and continues to operate 
with State support. 

94-027 State Rural Health Network Reform Initiative: 
Mississippi Rural Health Network Reform Initiative 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



50-P-90270/4 

August 1994-April 1996 

$ 240,000 

Grant 

Helen Wetherbee 

Mississippi Division of Medicaid 

239 North Lamar, Suite 801 

Jackson, MS 39211 

Sheldon Weisgrau 

Division of Delivery Systems and 

Financing 



Description: The State Rural Health Network Reform 
Initiative provided grant funds to States to develop 
innovations in rural health financing and delivery 
systems. The initiative was designed to enable States to 
address rural health issues within the context of 
comprehensive statewide and national health reform. 
Through a competitive process, a total of $1.7 million was 
awarded to the States of Florida, Minnesota, Mississippi, 
Nebraska, North Carolina, and Washington to support the 
planning, development, and implementation of new 
financing and delivery arrangements that enhance access 
to health care services and maintain a viable delivery 
system for rural residents. The initiative was originally 



Theme 3: Meeting the Needs of Vulnerable Populations 



171 



designed as a 3-year project, scheduled to conclude in 
August 1997. Funding for the second year of the program, 
however, was rescinded by Congress and no additional 
funds were appropriated. Participating States closed out 
program operations in April 1996. 

Status: The goal of this project was to develop a rural 
health care network in a five-county area of the 
Mississippi Delta, with hospitals supporting primary care 
services in outlying areas and ensuring specialty backup 
and referral services. The Mississippi Division of 
Medicaid anticipated that development of a network 
infrastructure and increased coordination of providers and 
resources would result in enhanced access to care and a 
decrease in inappropriate use of medical facilities in this 
area of the State. Several project development tasks were 
undertaken, including formation of a network planning 
committee consisting of providers, consumers, and 
community leaders, a survey of providers to determine the 
types of services available to residents of the Delta, and 
with support from the W.K. Kellogg Foundation, a survey 
of residents to gather information on health care needs. 
The State plans to utilize this information to review the 
appropriateness of the State's Medicaid benefit package 
and assist in the development of a Medicaid managed- 
care program. 

94-028 State Rural Health Network Reform Initiative: 
Nebraska Rural Health Network Reform Initiative 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



50-P-90260/7 
August 1994— April 

$ 228,880 
Grant 



1996 



HCFA Project 
Officer: 



David W. Palm, Ph.D. 

Nebraska Department of Health 

Office of Rural Health 

301 Centennial Mall South 

P. O. Box 95007 

Lincoln, NE 68509-5007 

Sheldon Weisgrau 

Division of Delivery Systems and 

Financing 



Description: The State Rural Health Network Reform 
Initiative provided grant funds to States to develop 
innovations in rural health financing and delivery 
systems. The initiative was designed to enable States to 
address rural health issues within the context of 
comprehensive statewide and national health reform. 
Through a competitive process, a total of $1.7 million was 
awarded to the States of Florida, Minnesota, Mississippi, 
Nebraska, North Carolina, and Washington to support the 
planning, development, and implementation of new 
financing and delivery arrangements that enhance access 



to health care services and maintain a viable delivery 
system for rural residents. The initiative was originally 
designed as a 3-year project, scheduled to conclude in 
August 1997. Funding for the second year of the program, 
however, was rescinded by Congress and no additional 
funds were appropriated. Participating States closed out 
program operations in April 1996. 

Status: This project was designed to accomplish a number 
of objectives, including development of capacity and 
infrastructure to assist rural communities in the financing 
and delivery of health care services, formation of 
multicounty rural health networks, development of 
managed-care models applicable to rural areas, and 
improvement of the exchange of patient care information 
between primary care physicians and specialists. To 
achieve these objectives, a State Rural Health Network 
Committee was formed and the Nebraska Office of Rural 
Health provided technical assistance to rural providers 
and communities on infrastructure development and 
network financing options. The State awarded grant 
funding to a rural network encompassing an eight-county 
area in southeast Nebraska to assist in developing 
financing and delivery strategies and network members 
and other stakeholders have investigated the development 
of various financing models. In addition, with the 
assistance of a panel of physicians brought together by the 
Center for Rural Health at the University of North 
Dakota, the State is developing guidelines for patient 
referrals from primary care providers to specialists within 
a network structure. 

94-029 State Rural Health Network Reform Initiative: 
North Carolina Rural Health Network Reform 
Initiative 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



50-P-90277/4 

August 1994-April 1996 

$ 172,964 

Grant 

Torlen Wade 

North Carolina Department of 

Human Resources 

Office of Rural Health and 

Resource Development 

31 1 Ashe Avenue 

Raleigh, NC 27606 

Sheldon Weisgrau 

Division of Delivery Systems and 

Financing 



Description: The State Rural Health Network Reform 
Initiative provided grant funds to States to develop 
innovations in rural health financing and delivery 
systems. The initiative was designed to enable States to 
address rural health issues within the context of 



72 



Theme 3: Meeting the Needs of Vulnerable Populations 



comprehensive statewide and national health reform. 
Through a competitive process, a total of $1.7 million was 
awarded to the States of Florida, Minnesota, Mississippi, 
Nebraska, North Carolina, and Washington to support the 
planning, development, and implementation of new 
financing and delivery arrangements that enhance access 
to health care services and maintain a viable delivery 
system for rural residents. The initiative was originally 
designed as a 3-year project, scheduled to conclude in 
August 1997. Funding for the second year of the program, 
however, was rescinded by Congress and no additional 
funds were appropriated. Participating States closed out 
program operations in April 1996. 



Status: This initiative was designed to develop a health 
care reform strategy for North Carolina's underserved 
rural communities. The project included an educational 
component to assist community-based providers in 
considering health reform and managed-care options, 
development of a network-based rural reform plan focused 
on the creation of local systems of care, and direct 
assistance to community-based primary care providers in 
organizing local delivery systems, meeting health plan 
requirements, and addressing community needs. The 
North Carolina Office of Rural Health and Resource 
Development created partnerships with a variety of other 
stakeholders, including the Division of Medical 
Assistance, associations representing hospitals, 
physicians, and other primary care providers, the 
Department of Insurance, the Kate B. Reynolds 
Foundation, and local and regional hospitals. A Managed- 
Care Workgroup was formed to guide network 
development, and a managed-care organization was 
created in collaboration with the North Carolina Primary 
Health Care Association. The Office of Rural Health and 
Resource Development also assisted with the development 
and implementation of the State's primary care case- 
management program for Medicaid beneficiaries. 

93-072 Study of State Health Care Reform Initiatives 

Project No.: 500-92-0033DO03 

Period: September 1993— December 1996 

Funding: $ 548,572 

Award: Delivery Order in Master Contract 

Principal 

Investigator: James Lubalin, Ph.D. 

Awardee: Research Triangle Institute 

(See page 132) 
HCFA Project Gloria J. Smiddy 
Officer: Office of State Health Reform 

Demonstrations 

Description: The purpose of this contract is to assist the 
Health Care Financing Administration's (HCFA) Office 
of Research and Demonstrations, and States, to develop 
and implement Medicaid program innovations and/or 



State health system reforms. The contract has three main 
objectives. The first is to document the progress of States 
that have begun reform efforts by creating a library of 
information that can be updated as the implementation of 
reform occurs. The second is to facilitate the streamlining 
of the section 1115 demonstration waiver process by 
providing recommendations to HCFA on how to revise 
and simplify the guidelines for project proposals, waiver 
cost estimates, and evaluation designs. The third is for the 
awardee to provide technical assistance to States, helping 
them through the development of demonstration 
proposals, evaluation designs, and issue papers. 

Status: In April 1996, the contract was extended until 
December 31, 1996. The project is in the final phase of 
operations. 

94-018 Study of the Natural History of End Stage 
Renal Disease in Persons with Diabetes 

Project No.: 500-92-002 1DO04 

Period: July 1994-June 1997 

Funding: $ 111,074 

Award: Delivery Order in Master Contract 

Principal 

Investigator: Robert J. Rubin, M.D. 

Awardee: Lewin/VHI, Inc. 

(Seepage 193) 
HCFA Project Paul W. Eggers, Ph.D. 
Officer: Division of Health Information and 

Outcomes 

Description: This project will analyze the natural 
progression of end stage renal disease (ESRD) among 
persons with diabetes to acquire further knowledge about 
the risk factors associated with this progression. This will 
be accomplished by linking the second National Health 
and Nutrition Examination Survey with the ESRD 
Program Management and Medical Information System at 
the Health Care Financing Administration (HCFA). The 
cumulative incidence of ESRD among persons identified 
as diabetic or having impaired glucose tolerance will be 
calculated and risk factors will be identified. 

Status:Relevant variables have been identified, and 
creation of the files for matching has begun. Privacy 
agreements between HCFA and, the National Center for 
Health Statistics are being finalized. 

91-098 Synthesis of Financing and Delivery of Long- 
Term Care for the Disabled Non-Elderly (Formerly, 
Long-Term Care Studies (Section 207)) 



Project No.: 


500-89-0047/30 


Period: 


June 1991-December 1995 


Funding: 


$ 30,000 


Award: 


Contract 



Theme 3: Meeting the Needs of Vulnerable Populations 



173 



Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



David Kennel 1 

Lewin/VHI, Inc. 

9302 Lee Highway, Suite 500 

Fairfax, VA 22031-1207 

Carolyn Rimes 

Division of Disability and Aging 



Description: This study synthesizes the current literature 
and information from various data sources on the 
financing and delivery of long-term care for the disabled 
non-elderly. This study also summarizes the current 
knowledge of demographic and economic characteristics 
of the disabled non-elderly, types of services and patterns 
of service use by the disabled non-elderly, how these 
services for the disabled non-elderly are paid, and other 
unique issues related to the disabled non-elderly. This 
work was completed by Joshua Wiener of the Brookings 
Institution under subcontract to Lewin/VHI, Inc. 

Status: Findings from this project are presented in the 
conference proceedings, Persons with Disabilities, from 
the Brookings Institute. The proceedings is available from 
the Brookings Institute. 

91-099 Synthesis of Literature on Effectiveness of 
Special Assistive Devices in Managing Functional 
Impairment (Formerly, Long-Term-Care Studies 
(Section 207)) 

Project No.: 500-89-0047/28 

Period: August 1991— January 1996 

Funding: $ 32,600 

Award: Contract 

Principal 

Investigator: David Kennell 

Awardee: Lewin/VHI, Inc. 

(See page 17) 

HCFA Project Carolyn Rimes 

Officer: Division of Aging and Disability 

Description: This synthesis has two components. The first 
is a description of the special assistive devices and a 
summary of how these devices are paid for under the 
current system. The second is a summary of the 
effectiveness of special assistive devices in managing 
functional impairments. This synthesis also discusses 
various policy options, which relate to alternative 
financing arrangements for special assistive devices. The 
analysis of assistive device usage is obtained using the 
1984 Supplement on Aging and the 1990 National Health 
Interview Survey Supplement on Assistive Devices. 

Status: This first draft has been received and is expected 
to be completed in January 1997. 



91-100 Synthesis of Literature on Targeting to 
Reduce Hospital Use (Formerly, Long-Term-Care 
Studies (Section 207)) 

Project No.: 500-89-0047/5 

Period: September 1991-August 1995 

Funding: $ 30,000 

Award: Contract 

Principal 

Investigator: David Kennell 

Awardee: Lewin/VHI, Inc. 

(See page 17) 

HCFA Project Carolyn Rimes 

Officer: Division of Aging and Disability 

Description: This study synthesizes the literature on 
targeting across a variety of types of programs, all of 
which have the goal of reducing hospital use.These 
programs include geriatric evaluation units, nursing home 
staffing enhancement programs, and hospital-based 
programs for discharge planning and transitional case 
management. Although targeting is an issue for all of 
these types of programs, little attention has been given to 
evaluating targeting criteria. This project has been 
subcontracted to Mathematica Policy Research, Inc. 

Status: This review of the literature points to familiar 
gaps in the current health care system. The review 
discusses the lack of overall coordination and monitoring 
of care for the elderly, an insufficient level of primary and 
acute care for nursing home patients, poor access to a 
range of subacute services, a shortage of physicians with 
geriatric training for community-dwelling elderly persons, 
and insufficient efforts to reduce the highest cost diseases 
and complications that arise during hospitalization. The 
literature also suggests that several groups of elderly 
might benefit from such interventions as comprehensive 
geriatric assessment, enhanced hospital discharge 
planning, and the social health maintenance organization. 
These groups include individuals whose conditions are 
difficult to stabilize or who require regimens of 
medications or diet that must be monitored for compliance 
or change, individuals for whom medications are likely to 
lead to adverse events, and individuals facing nursing 
home placement without first being evaluated for 
rehabilitative potential. 

96-074 Technical Assistance Program on Accessing 
and Utilizing HCFA's Medicare/Medicaid Data for 
Historically Black Colleges and Universities (HBCUs) 
Faculty Members and Researchers 

Project No.: 360-96-90080 

Period: September 1 996-September 1997 

Funding: $ 50,000 

Award: Contract 



174 



Theme 3: Meeting the Needs of Vulnerable Populations 



Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Johnnie R. Jackson, Ph.D. 

Biotechnology and Environmental 

Services (BITES), Inc. 

8401 Corporate Drive, Suite 270 

Landover, MD 20716 

Richard Bragg 

Division of Aging and Disability 



Description: The Technical Assistance Program on the 
Access and Use of the Health Care Financing 
Administration's (HCFA's) Medicare/Medicaid Data 
contract is to enhance the capacity of HBCU faculty 
members and researchers to participate in the broad array 
of HCFA program activities. Interested HBCU staff will 
be trained on accessing and utilizing Medicare and 
Medicaid data. The training will be for the awardees of 
the 1996 Historically Black Colleges and Universities 
Grants Program and other HBCU data users. Researchers 
will become familiar with HCFA data analyses in a 
problem oriented learning environment. Training will be 
provided on an individual basis through consultative 
services, and a group session (15-20 persons) for a 2-day 
period. A hands-on data laboratory curriculum will be 
developed in conjunction with HBCU faculty and 
researchers' identified priorities. 

Status: This project is in its early design phase. 
96-043 Tennessee "Families First" Demonstration 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



11-W-00 104/4 

September 1996— September 2006 

Waiver-only Project 

Linda Rudolph 

Department of Human Services 

400 Deaderick Street 

Citizens Plaza Building 

Nashville, TN 37248 

Alisa Adamo 

Office of State Health Reform 

Demonstrations 



Description: This is an innovative welfare reform project. 
There are time limits and various incentives for people to 
go to work. Medicaid waivers were needed in order to 
provide 18 months of transitional Medicaid to people 
regardless of the reason for Aid to Families and 
Dependent Children (AFDC) case closure and regardless 
of whether the person was on AFDC for 3 out of the 
preceding 6 months. 

Status: The project began operation on September 1, 
1996. With the August 22, 1996 enactment of the 
Personal Responsibility and Work Opportunity 
Reconciliation Act of 1996 (PRWORA), it is anticipated 



that the Title IV-A component of this demonstration will 
be modified. However, the impact of the PRWORA is 
being analyzed. 

94-080 Tennessee TennCare 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00002/4 

January 1994-December 1998 

Waiver-only Project 

Theresa Clarke 

Tennessee Department of Health 

TennCare Bureau 

729 Church Street 

Nashville, TN 37247-6501 

Rose M. Hatten 

Office of State Health Reform 

Demonstrations 



Description: TennCare is a statewide program to provide 
health care benefits to Medicaid beneficiaries, uninsured 
State residents, and those whose medical conditions make 
them uninsurable. Enrollment will be capped at 
1,300,000. If the cap is reached, those in mandatory 
Medicaid coverage groups and the uninsurables will 
continue to be enrolled, while the currently uninsured 
group enrollment will be limited. All enrollees are served 
in capitated managed-care plans. 

Status: The program began on January 1, 1994. Current 
enrollment is about 1.2 million. About 330,000 of these 
enrollees are in the uninsured and uninsurable groups. On 
July 1, 1996, the State implemented a carve-out program 
to bring the severely and persistently mentally ill into 
managed care. Two behavioral health organizations cover 
behavioral health services for the entire TennCare 
population. 

96-041 To Strengthen Michigan Families 

Project No.: ll-W-00093-5 

Period: August 1996-August 1999 

Award: Waiver-only Project 

Principal 

Investigator: Gerald Miller 

Awardee: Department of Social Services 

P. O. Box 30037 

Lansing MI 48909 
HCFA Project Alisa Adamo 
Officer: Office of State Health Reform 

Demonstration 

Description: Michigan is currently operating an 1115 
Welfare Reform Demonstration entitled, "To Strengthen 
Michigan Families." The demonstration began in 
October 1992 and will end on September 30, 1999. The 
overall demonstration emphasizes personal responsibility 



Theme 3: Meeting the Needs of Vulnerable Populations 



175 



and work. A new component of the demonstration, 
"'Project Zero," required Medicaid waivers that were 
awarded in 1996. 

Project Zero is occurring in six sites in five counties 
(Alpena, Menominee, Midland, Ottawa and Wayne; the 
Wayne county pilot will operate in two of the county's 
districts — Romulus and Tireman). Project Zero began in 
March 1996. The goal of the project is to reduce the 
percentage of AFDC cases without earnings to zero. The 
pilot has two phases. In phase one, Aid to Families with 
Dependent Children (AFDC) clients were surveyed to 
determine demographic information, information related 
to employability, and real and perceived barriers to care. 

Phase two involves the development and implementation 
of programs to facilitate employment and achievement of 
the pilot's goals. One of the programs that will be offered 
is a Medicaid buy-in for families whose transitional 
Medicaid has expired. Other programs being offered are a 
privately subsidized transportation system, a 24-hour day 
care center, and expanded support services under the Jobs 
Opportunity and Basic Skills (JOB) program. 

Approximately 7,000 AFDC cases will be targeted for 
Project Zero. About one-third of those cases (2,500 cases) 
are expected to work their way off of AFDC and to get 
transitional Medicaid. Once their transitional Medicaid 
expires, they will be given an offer to buy-in to Medicaid 
as long as they don't have access to any other health 
insurance and have incomes below 185 percent of the 
Federal poverty level. If they accept the offer to buy-in, 
the individuals and the State would pay the State share of 
the premium and the Federal Government would match 
the premium. The rates for the buy-in are based on 
actuarial determined rates set for health maintenance 
organizations (HMO) in Michigan. Eligibility for the buy- 
in will be redetermined on an annual basis. 

Status: The Medicaid buy-in portion of Project Zero just 
began operations, so there are no results to report. With 
the August 22, 1996 enactment of the Personal 
Responsibility and Work Opportunity Reconciliation Act 
of 1996 (PRWORA), it is anticipated that the Title IV-A 
component of this demonstration will be modified. 
However, the impact of the PRWORA is being analyzed. 

96-071 Use of Educational Intervention Programs in 
African American Communities to Decrease the Racial 
Disparity in Access to and Utilization of Heart and 
Vascular Procedures 

Project No.: 20-C-907 16/3-01 

Period: September 1996-September 1998 

Funding: S 175,622 

Award: Cooperative Agreement 



Principal 

Investigator: Dorothy M. Mattison, Ph.D. 

Awardee: University of Maryland Eastern Shore 

Department of Business and Economics 

Princess Anne, MD 21853 
HCFA Project Richard Bragg 
Officer: Division of Aging and Disability 

Description: The project aims to reduce the racial 
differences in access and utilization of high cost cardio- 
vascular surgical procedures by Medicare beneficiaries. It 
involves an evaluation of the extent of prevailing racial 
differences and the development and implementation of 
an educational intervention. It will include developing 
and administering novel educational programs in local 
African-American communities and identifying barriers 
to utilizing high quality, perhaps cost-efficient and 
vascular surgical procedures. Specifically, an analysis of 
African-American Medicare beneficiary utilization rates 
of cardiovascular surgical procedures performed in the 
hospital will be done. A comparison will be made between 
the availability and utilization on the study procedures for 
African-American and white Medicare beneficiaries. An 
education intervention is being utilized in the form of 
seminars and workshops conducted at senior citizen 
centers, churches, and civic and community organization 
meetings. The goal with this effort is to provide an 
awareness of treatment choices for specific heart and 
vascular conditions. 

Status: This project is in its early design phase. 

94-084 Use of Long-Term Care Services by 
Mentally 111 Persons 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



17-C-90341/3 

September 1994-December 1996 

$ 391,331 

Cooperative Agreement 



Dennis Shea, Ph.D. 

Center for Health Policy Research 

Institute for Policy Research and 

Evaluation 

Pennsylvania State University 

Office of Sponsored Programs 

1 10 Technology Center 

University Park, PA 16802 

HCFA Project Feather Ann Davis, Ph.D. 

Officer: Division of Aging and Disability 

L 

Description: There has been a steady increase in the 
utilization of long-term-care services, particularly nursing 
homes, by mentally ill persons following the closure of 
State and county mental hospitals during the 1960s and 
1970s. This project examines the determinants of long- 
term-care service use by the mentally ill population. Data 



176 



Theme 3: Meeting the Needs of Vulnerable Populations 



from the National Medical Expenditures Survey (NMES) 
Institutional Component, the Medicare Current 
Beneficiary Survey (MCBS), and the National Nursing 
Home Survey (NNHS) are being used to model long-term- 
care use by this population. Information on patients, 
providers, and system characteristics, together with a more 
complete description of current use patterns, will help to 
identify the potential impacts of policy changes on use of 
services and total program costs. 

Status: Descriptive data from the Institutional Population 
Component of the 1987 National Medical Expenditure 
Survey (NMES) have been used to examine differences in 
nursing home expenditures by persons with and without 
reported or diagnosed mental illness. The results 
presented in "Mental Illness and Nursing Home Use," 
presented at the 1995 Meetings of the Gerontological 
Society of America indicate the following: 

• Mental illnesses explain variations in service use, with 
the effects depending on how mental illness is defined 
and whether a resident or admission cohort is 
examined. 

• Newly admitted nursing home residents with a mental 
illness have higher charges due to lengths of stay that 
are 35 percent longer than non-mentally ill admissions. 

• Charges vary little between persons with or without a 
mental illness. 

These results suggest that if future reimbursement policy 
in long-term-care settings is moving toward capitation, as 
has occurred in other settings, rates should take into 
account the longer stay associated with persons with 
mental illness. 

Results from the initial descriptive analyses of the MCBS 
indicate that 5 years after the passage of the 1987 Nursing 
Home Reform Act, which mandated treatment of mental 
illnesses, there is a persistent level of untreated mental 
illness in nursing homes. Only 29 percent of nursing home 
residents with a mental illness were treated by mental 
health specialists during the year. Regarding the use of 
other long-term-care services, a significant relation has 
also been detected between diagnosis of a mental illness 
and home health use. 

92-066 Utah Welfare Reform: Single-Parent 
Employment Demonstration 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 



ll-W-00019/8 

September 1992-October 1996 

Waiver-only Project 

Janet Hansen 



Awardee: Utah Department of 

Human Services 

120 North 200 West, Suite 325 

P. O. Box 45500 

Salt Lake City, UT 84145-0500 
HCFA Project Maria Boulmetis 
Officer: Office of State Health Reform 

Demonstrations 

Description: This demonstration has waivers from the 
Health Care Financing Administration, the 
Administration for Children and Families, and the 
Department of Agriculture (Food Stamps). Under this 
project, to divert them from welfare, applicants for Aid to 
Families with Dependent Children (AFDC) who appear to 
have short-term need are given a one-time cash payment 
equivalent to 3 months of an AFDC grant and 3 months 
of Medicaid coverage in Utah. Those with longer-term 
needs receive a cash equivalent of Food Stamps, regular 
monthly AFDC payments, and an incentive payment to 
participate in employment-related activities, with a larger 
financial deterrent for non-attendance. Those who become 
employed receive a higher disregard of earnings than 
current law allows, and those who work their way off 
welfare receive 12 months of Food Stamp cash equivalent 
and a 24-month Medicaid extension, with no income limit 
during the extension period. Individuals whose Medicaid 
transitional benefits have been terminated for failure to 
file a report will also not be penalized and will continue to 
receive the transition benefit after they file an income 
report. (Current law provides a 6-month Medicaid 
extension, regardless of income, with an additional 
6 months contingent upon earnings below 185 percent of 
the Federal poverty level.) There will also be an 
additional income disregard for child-support income 
toward determining AFDC-related Medicaid eligibility. 

Status: The State is continuing to implement the 
demonstration. With the August 22, 1996 enactment of 
the Personal Responsibility and Work Opportunity 
Reconciliation Act of 1996 (PRWORA), it is anticipated 
that the Title IV-A component of this demonstration will 
be modified. However, the impact of the PRWORA is 
being analyzed. 

96-068 Utilization of Mammography Services Among 
Elderly African-American Women: Educational 
Intervention and Research Project 



Project No. : 

Period: 

Funding: 

Award: 

Principal 

Investigator: 



20-C-90707/4-01 
September 1996-May 1998 
$ 245,276 
Cooperative Agreement 

Augustine O. Ogho, Ph.D. 



Theme 3: Meeting the Needs of Vulnerable Populations 



177 



Awardee: 



HCFA Project 
Officer: 



Florida Agricultural and Mechanical 

University 

Martin Luther King Boulevard 

Tallahassee. FL 32307 

Richard Bragg 

Division of Aging and Disability 



Description: The purpose of this research/demonstration 
project is to implement an educational intervention 
program. The intervention is designed to increase the 
level of awareness among elderly African-American 
women who are Medicare recipients regarding Medicare 
coverage for mammography screening and clinical breast 
examination. The intervention is also designed to increase 
their knowledge of the benefits of these services, thus 
increasing their utilization of these life-saving 
technologies. The research component is designed to 
identify 2 rural and 2 urban counties, and to analyze the 
Health Care Financing Administration's 1995 claims file 
and to develop baseline screening rate for Medicare 
beneficiaries in those counties. Women in these counties 
will then receive intervention and changes in screening 
rates will be evaluated. 

Status: This project is in its early design phase. 
95-021 Vermont Health Access Plan 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00051/1 

August 1995-July 2001 
Waiver-only Project 

Cornelius D. Hogan 

Vermont Agency of Human Services 

103 South Main Street 

Waterbury, VT 05671 

Sherrie L. Fried 

Office of State Health Reform 

Demonstrations 



Description: The Health Care Financing Administration 
has approved Vermont's section 1115 Medicaid 
demonstration proposal, "Vermont Health Access Plan" 
(VHAP). Vermont will make comprehensive health care 
coverage available to approximately 90,500 individuals, 
including 64,000 individuals currently eligible for 
coverage under Vermont's Medicaid program, and 26,500 
uninsured poor who will become newly eligible. VHAP 
will implement a statewide mandatory Medicaid 
managed-care program. The program began on 
January 1, 1996, and will operate for 5 years. The 
demonstration will provide health care services to 
uninsured lower-income Vermonters (up to 150 percent of 
the Federal poverty level [FPL]); provide a Medicaid 
prescription-drug benefit to the State's lower-income 
Medicare beneficiaries (up to 150 percent FPL); and 



improve access, service coordination, and quality of care 
through the implementation of a managed-care delivery 
system. 

Status: Because managed-care plans are not in place at 
the start of the demonstration, an interim limited-benefit 
package is available on a fee-for-service basis to low- 
income uninsured adults. This program covers ambulatory 
services for eligible individuals on a transitional basis 
until they can enroll in managed-care health plans. 
Among the covered services are physician services, 
outpatient hospital services, prescription medicines, and 
other outpatient services. Inpatient hospital care is not 
covered. Enrollment into managed care began on 
October 1, 1996. Individuals enrolled in the interim 
limited-benefit package will be phased into managed care. 

93-063 Vermont Welfare Reform: Family 
Independence Project (Formerly, Vermont Family 
Independent Program) 



Project No.: 


ll-P-90238/1 


Period: 


July 1993-June2001 


Award: 


Waiver-only Project 


Principal 




Investigator: 


Cornelius D. Hogan 


Awardee: 


Vermont Agency of Human Services 




103 South Main Street 




Waterbury, VT 05676 


Project 


Alisa Adamo 


Officer: 


Office of State Health Reform 




Demonstrations 



Description: This demonstration has waivers from the 

Health Care Financing Administration, the 

Administration for Children and Families, and the 

U. S. Department of Agriculture (Food Stamps). The 

demonstration requires single-parent cases in Vermont 

who have been eligible for Aid to Families with 

Dependent Children (AFDC) for more than 30 months 

and two-parent cases who have been eligible for AFDC 

for more than 15 months to participate in subsidized 

employment. Demonstration waivers also broaden AFDC 

eligibility for two-parent cases, require most parents of 

minors to live in a supervised setting, increase the 

disregard of earnings and assets in determining AFDC 

eligibility, permit disbursement of child-support payments 

to the AFDC family, permit the State to give incentive 

payments to AFDC parents who successfully complete 

parenting-education classes or other approved activities, 

and make income eligibility the same for AFDC and Food 

Stamps. i 

i 
Medicaid waivers allow families who work their way off 

welfare to have a maximum 36-month Medicaid transition 

benefit, in quarterly increments, as long as the family's 

income is below 185 percent of the Federal poverty level 



178 



Theme 3: Meeting the Needs of Vulnerable Populations 



(in lieu of current law's maximum 12-month Medicaid 
transition benefit). Medicaid waivers also allow the State 
to reduce the AFDC grant while allowing them to 
compute the medically needy income level based on the 
AFDC grant before it was reduced. 

Status: Demonstration waivers were implemented 
July 1, 1994. With the August 22, 1996 enactment of the 
Personal Responsibility and Work Opportunity 
Reconciliation Act of 1996 (PRWORA), it is anticipated 
that the Title IV-A component of this demonstration will 
be modified. However, the impact of the PRWORA is 
being analyzed. 

95-063 Virginia Independence Program 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-0062/3 

July 1995-June2003 

Waiver-only Project 

Kay Cole James 

Virginia Department of Health and 

Human Services 

P. O. Box 1475 

Richmond, VA 23212 

Maria Boulmetis 

Office of State Health Reform 

Demonstrations 



Description: Statewide, the Virginia Independence 
Program (VIP) will provide one-time diversion payments 
to applicants instead of Aid to Families with Dependent 
Children (AFDC); tighten jobs opportunity and basic 
skills training program sanction; require paternity 
establishment within 6 months; require minor parents to 
live with adult guardians; eliminate benefit increase for a 
baby born to a mother on welfare; require AFDC care- 
takers without a high school diploma to attend school; 
require child immunizations; increase resource limits; and 
give transitional child care and Medicaid benefits to cases 
losing AFDC eligibility for any reason, and if they have 
no coverage through an employer group health plan and 
have incomes below 185 percent of Federal poverty 
guidelines (FPG). The Virginia Initiatives for Employ- 
ment not Welfare (VIEW) would phase in statewide a 
program over 4 years that will assign participants to a 
work activity, within 90 days of benefit receipt; provide 
employer subsidies from AFDC plus the value of Food 
Stamps; time-limit AFDC benefits to 24 consecutive 
months; apply full-family AFDC cash sanctions for 
refusal to cooperate with work programs; increase earned- 
income disregards up to FPG; and provide 12 months of 
transitional transportation assistance. 

Status: In their most recent quarterly report, the State 
reported a decline in AFDC cases and payments under the 
VIP demonstration with a rise in AFDC-Unemployed 



Parent cases and payments. Regarding the VIEW data, the 
employment rate for those who apply for AFDC benefits 
was 66 percent in one of the economic development 
districts and 39 percent in another. With the August 22, 
1996 enactment of the Personal Responsibility and Work 
Opportunity Reconciliation Act of 1996 (PRWORA), it is 
anticipated that the Title IV-A component of this 
demonstration will be modified. However, the impact of 
the PRWORA is being analyzed. 

88-002 Wisconsin State Welfare Reform 
Demonstration (Formerly, Wisconsin Welfare Reform 
Demonstration) 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00041/5 

October 1987- September 1997 

Waiver-only Project 

J. Jean Rogers 

Wisconsin State Department of Health 

and Social Services 

P. O. Box 7935 

Madison, WI 53707-7850 

Maria Boulmetis 

Office of State Health Reform 

Demonstrations 



Description: This demonstration had waivers from the 
Administration for Children and Families (ACF) and the 
Health Care Financing Administration permitting: 

• Some persons receiving Aid to Families with 
Dependent Children (AFDC) to work 40 hours per 
week rather than the law's limit of 20 hours. 

• Major changes in the disregard of earnings, with less 
being disregarded in the initial 4 months of work and 
more in the subsequent 8 months. 

• A Medicaid extension of 12 months for recipients who 
lose AFDC eligibility because of earnings, regardless of 
income increases during the extension period. (The 
Family Support Act law provides a 6-month Medicaid 
extension, regardless of income, with an additional 

6 months contingent upon earnings below 1 85 percent 
of the Federal poverty level.) 

Wisconsin implemented its 12-month Medicaid extension 
in February 1989 experimentally, with a pre-Family 
Support Act control group receiving a 4- or 9-month 
extension of Medicaid. In April 1990, the State 
implemented the Medicaid waiver statewide, with no 
control group. Therefore, the initial evaluation contrasted 
a full 12-month Medicaid extension with a 4- or 9-month 
extension for earners who worked their way off welfare. 

The evaluation found that there was no significant 
difference in AFDC caseload, overall AFDC costs, or 
earnings between cases who had received a 12-month 



Theme 3: Meeting the Needs of Vulnerable Populations 



179 



Medicaid extension and those who had received only 4-or 
9-months. However, 76 percent of the cases with a 
12-month Medicaid extension, in contrast to 73 percent of 
those with 4- or 9- months, left welfare some time during 
the 14-month study period. Among these closed cases, 
27 percent of those with a 12-month Medicaid extension 
returned to welfare within the study period, in contrast to 
30 percent of those with a 4- or 9-month extension. The 
evaluators concluded that the longer extension did not 
provide an incentive for cases to leave AFDC, but did 
help to reduce welfare recidivism. 

Status: The AFDC waivers ended in July 1995, and 
therefore there is no longer an AFDC component of this 
demonstration. However, the State has been granted an 
extension of the Medicaid waiver through September 
1997 as part of its effort to implement the welfare reform 
legislation under the Personal Responsibility and Work 
Opportunity Reconciliation Act of 1996. The State's 
Temporary Assistance for Needy Families Plan which 
replaces its AFDC State Plan has been certified. 

92-042 Wisconsin Welfare Reform: Two-Tier Aid to 
Families with Dependent Children Benefit 
Demonstration (Formerly, Two-Tier Aid to Families with 
Dependent Children Benefit Demonstration) 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-P-90 167/5 

July 1992-January 1999 

Waiver-only Project 

J. Jean Rogers 

Wisconsin State Department of 

Health and Social Services 

P. O. Box 7935 

Madison, WI 53707-7850 

Maria Boulmetis 

Office of State Health Reform 

Demonstrations 



Description: The project will measure the impact of Aid 
to Families with Dependent Children (AFDC) benefit 
levels on interstate migration among low-income families. 
This will be accomplished by paying families in up to six 
selected counties at a rate based on the benefit rate in 
their State of prior residence during their first 6 months in 
Wisconsin. Under the demonstration, a family will receive 
a benefit amount available to a typical family of the same 
size in the prior State of residence if the recipient applies 
for benefits within 180 days after moving to Wisconsin. A 
waiver of section 1902(c)(1), the maintenance of effort 
provision of the Medicaid law, has been approved to 
permit the State to obtain approvals of new State plans for 
medical assistance, even though the AFDC payment levels 
under the project will be below those levels in effect as of 
May 1, 1988. In addition, under the authority of section 



1 1 15(a)(2) of the Social Security Act, the following 
expenditures will be regarded as expenditures under the 
State's Title XIX plan: expenditures to permit the State to 
maintain the eligibility level for its medically needy 
program at 133 Vz percent of the current AFDC payment 
level, as specified under section 1903 (f)(1), while the 
State reduces payments under the Two-Tier AFDC Benefit 
Demonstration. 

Status: The State continues to implement the 
demonstration. With the August 22, 1996 enactment of 
the Personal Responsibility and Work Opportunity 
Reconciliation Act of 1996 (PRWORA), it is anticipated 
that the Title IV-A component of this demonstration will 
be modified. However, the impact of the PRWORA is 
being analyzed. 

94-067 Wisconsin Welfare Reform: 
Work Not Welfare 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



ll-W-00009/8 
November 1993- 
Waiver only 
Grant 



December 2005 



J. Jean Rogers 

Wisconsin State Department of Health 

and Social Services 

P. O. Box 7935 

Madison, WI 53707-7935 

Maria Boulmetis 

Office of State Health Reform 

Demonstrations 



Description: This demonstration has waivers from the 
Health Care Financing Administration, the 
Administration for Children and Families (AFDC), and 
the Department of Agriculture (Food Stamps) to do the 
following in two counties in Wisconsin: 

• Consolidate the AFDC and Food Stamps grant into a 
single cash payment. 

• Provide no increase in the cash grant for children born 
on welfare. 

• Limit cash benefits to 24 months in a 60-month period. 

• Eliminate the restriction on hours of employment for 
two-parent families. 

• Limit the family to 12 months of Medicaid and child- 
care transition benefits within a 48-month period. 

• Permit the State to require that recipients pay a 
premium for health insurance that exceeds 3 percent of 
their income during any part of the transition benefit 
period (current law limits this to the second 6 months of 
the 12-month transition period). 

Status: The State continues to implement the 
demonstration. With the August 22, 1996 enactment of 
the Personal Responsibility and Work Opportunity 



180 



Theme 3: Meeting the Needs of Vulnerable Populations 



Reconciliation Act of 1996 (PRWORA), it is anticipated 
that the Title IV-A component of this demonstration will 
be modified. However, the impact of the PRWORA is 
being analyzed. 

Intramural 

IM-059 Childhood Injuries in the Medicaid Population 

Funding: Intramural 

HCFA Project David Baugh, Suzanne Rotwein, Ph.D., 

and Rosemarie Hakim, Ph.D. 
Directors: Division of Health Information and 

Outcomes 

Description: Injuries are a significant cause of mortality 
and morbidity in the U. S. population, particularly among 
persons under 2 1 years of age, and among the vulnerable 
populations served by Medicaid. Little is known about the 
incidence, prevalence, and program expenditures for 
injuries under Medicaid. This study will provide baseline 
data on utilization and payments for injuries by Medicaid 
in selected States. Since many injuries are preventable, 
this effort will lead to other studies which should assist us 
in understanding the extent and types of injuries 
experienced by Medicaid enrollees and provide input to a 
process of preventing injuries and containing cost for 
injuries within Medicaid. 

Status: The study is in the design phase. 

IM-048 Development Activities of the HBCU Network 

Funding: Intramural 

HCFA Project Richard Bragg 

Director: Division of Aging and Disability 

Description: Utilizing a networking system, the 
Historically Black Colleges and Universities (HBCUs) are 
able to: 

• Channel health related research information. 

• Stimulate the need for culturally sensitive research. 

• Provide technical assistance for addressing the unique 
health needs of African Americans and other 
minorities. 

• Facilitate the cohesion of a strong core of researchers 
with experience in and sensitivity to health-related 
research on the African-American community. 

The purposes of the HBCU Network are to: 

• Develop and foster research on the health needs of 
African Americans and to help reduce differentials in 
health status between African-Americans and whites. 

• Set priorities on health research needs in African- 
American populations. 



• Encourage collaborative research by bringing together 
institutions and individuals concerned with increasing 
health-related research in African-American 
populations in order to create a regional, cultural mass 
of relevant expertise. 

• Develop a coordinated program to increase the number 
of African- American health researchers. 

Status: The project is under development. 

IM-067 Dialysis Modality Selection Among Patients 
Attending Freestanding Dialysis Facilities 

Funding: Intramural 

HCFA Project Michael Kendix, Ph.D. 
Director: Division of Health Information and 

Outcomes 

Description: Persons with end stage renal disease (ESRD) 
are eligible to receive dialysis services under the Medicare 
program. An individual-level analysis was performed to 
determine the factors associated with the modality 
selected by patients; namely in-center hemodialysis, 
continuous ambulatory peritoneal dialysis (CAPD), 
continuous cycling peritoneal dialysis (CCPD), and home 
hemodialysis. A series of logistic regressions was 
estimated using program data for 73,448 ESRD Medicare 
patients attending freestanding dialysis facilities. The 
results showed first, that ethnic minorities are less likely 
to select CAPD, CCPD, and home hemodialysis. Second, 
income was positively associated with selecting a home- 
based modality. Third, patients attending for-profit 
dialysis facilities were less likely to select CAPD, CCPD, 
and home hemodialysis. Fourth, patients attending 
facilities owned by a large chain were less likely to select 
CAPD and home hemodialysis, but more likely to select 
CCPD. Fifth, patients who were younger, had non- 
systemic precipitating causes of ESRD, and a shorter 
duration of ESRD, were more likely to select CAPD and 
CCPD. Sixth, women were more likely to select CAPD 
and less likely to select home hemodialysis. Finally, 
patients in larger facilities are more likely to select CAPD, 
CCPD, and home hemodialysis; that is, there are 
economies of scale with respect to these modalities being 
selected. 

Status: The project is in the final stages. 

IM-60 Early, Periodic Screening, Diagnosis and 
Treatment (EPSDT) Program Trend Analysis 

Funding: Intramural 

HCFA Project Suzanne Rotwein, Ph.D. and 

Rosemarie Hakim, Ph.D. 
Directors Division of Health Information and 

Outcomes 



Theme 3: Meeting the Needs of Vulnerable Populations 



181 



Description: The Medicaid Program is mandated to 
provide EPSDT to enrolled children between birth and 
21 years of age. In 1967, Congress established EPSDT, a 
program designed to encourage Medicaid-eligible families 
to adopt a pattern of preventive health care for their 
children, and Congress authorized Federal funds for States 
that provided health screening, diagnosis, and treatment 
for eligible children and adolescents. EPSDT requires 
States to inform eligible families about the program, 
provide or arrange for screening, arrange for necessary 
treatments covered by the March 1996, Publication 
Number 03380, State's Medicaid program, and provide 
supportive services such as transportation to facilitate their 
participation in the program. As EPSDT has developed, it 
has grown from a narrowly defined health screening 
program toward a total health service delivery system for a 
large segment of the population which has not been 
receiving adequate health care. The purposes of this 
project are to provide an overview of utilization and 
expenditure patterns of children who receive EPSDT 
services and examine health outcomes of children 
regarding use of EPSDT and follow-up services in 
California, Georgia, and Michigan in 1989 and 1992. 

Status: The project is in the design phase. 

IM-004 End Stage Renal Disease 
Annual Research Report 

Funding: Intramural 

HCFA Project Paul W. Eggers, Ph.D. 
Director: Division of Health Information and 

Outcomes 

Description: The annual reports are designed to produce a 
wide range of data and analyses regarding the end stage 
renal disease (ESRD) program. Many of the data in these 
reports emphasize trends and comparisons over time, 
making these reports standard reference sources 
illustrating changes in the nature of the Medicare ESRD 
population and in the pattern of treatment of this 
population. 

Status: The most recent published report is the Health 
Care Financing Administration: Research Report: End 
Stage Renal Disease, 1992. HCFA Publication Number 
03359. Bureau of Data Management and Strategy. 
Washington, D. C. U.S. Government Printing Office, 
September 1994. Complimentary copies of this report are 
available from the Health Care Financing Administration, 
Bureau of Data Management and Strategy, Office of 
Systems Management, Division of Program Systems, 
N2- 14-04, 7500 Security Boulevard, Baltimore, Maryland 
21244-1850. Telephone requests can be made to 
(4 10)786-0069. 



IM-047 Inventory of Projects with Special Focus on 
African Americans and Other Minorities 

Funding: Intramural 

HCFA Project Richard Bragg 

Director: Division of Aging and Disability 

Description: The objectives of this project are to: 

• Inventory Office of Research and 
Demonstrations research, evaluation, and 
demonstration projects to determine their effects on 
African Americans as related to health status, access to 
service, utilization, and out-of-pocket expenditures. 

• Determine the participation of African-American 
populations in extramural and intramural research 
efforts related to the health care delivery service. 

• Promote the Health Care Financing Administration's 
research that will be aimed at developing a better 
understanding of health care services issues pertaining 
to African Americans. 

• Prepare a compendium that emphasizes aforementioned 
activities. 

Status: This project is under development. 

IM-072 Longitudinal Study of Use of Early Preventive 
Services and Health Outcomes of a Nationally 
Representative Cohort of Children Born in 1988 
and Followed-Up at Age Three 

Funding: Intramural, $30,000 support from 

National Center for Health Statistics 

HCFA Project Rosemarie Hakim, Ph.D. 

Director: Division of Health Information 

Outcomes 

Description: The project will use the National Maternal 
and Infant Health Survey and the 1991 Longitudinal 
Follow-Up Survey to examine the effects of use of early 
preventive health care on health outcomes to test the 
hypothesis that adequate use of services improves the 
health and well-being of children. The survey contains 
extensive provider information as well as interview-based 
information on each child's health and use of services. 
Children covered under private insurance, Medicaid, and 
uninsured are in the sample. Health outcomes will include 
growth and cognitive development as well as common 
child health indicators such as immunizations and 
respiratory infections. Factors such as barriers to care, 
income, race, and continuity of care can be used to predict 
health outcomes. 

Status: This project is a joint effort between Health Care 
Financing Administration and the National Center for 
Health Statistics. It is currently in the planning stages. 



82 



Theme 3: Meeting the Needs of Vulnerable Populations 



IM-012 Patterns and Outcomes of Cancer Care 
in the Medicare Population 

Funding: Intramural 

Project Gerald F. Riley, James D. Lubitz, 

Directors: and Renee Mentnech 

Division of Health Information 

and Outcomes 

Description: More than one-half of all cancer patients 
have Medicare coverage. A database that links Medicare 
data with cancer registry data collected through the 
National Cancer Institute's Surveillance, Epidemiology, 
and End Results (SEER) program has been created. The 
SEER program covers approximately 10 percent of the U. 
S. population. This database contains information on the 
anatomic site of the primary cancer, histology, stage of 
the disease at diagnosis, and date of diagnosis for each 
new case of cancer in the program's geographic areas. 
Linking SEER and Medicare data provides opportunities 
for research on issues of access to medical care, Medicare 
costs incurred by cancer patients, and patterns of medical 
care received by cancer patients diagnosed with various 
sites, stages, and histologies of cancer. Some specific 
questions to be addressed are: 

• What are overall Medicare costs, by type and stage of 
cancer? 

• What are the Medicare costs that are specifically related 
to cancer care? 

• What comorbidities are associated with cancer and how 
do they influence Medicare use and cost? 

• What is the mix of care (on a per-person basis) among 
community hospitals, teaching hospitals, and cancer 
centers? 

• What are the institutional factors that influence the type 
of inpatient hospital care received by cancer patients? 

Status: SEER and Medicare data have been linked for 
10 registries for all cases diagnosed from 1973 to 1993. 
The following article has been published describing the 
linked database: Potosky, A. L., Riley, G. F., Lubitz, J. D., 
et al.: "Potential for Cancer-Related Health Services 
Research Using a Linked Medicare Tumor-Requesting 
Data Base." Medical Care, Volume 31, pp. 732-7 '47, 
1993. 

An article describing Medicare payments for cancer 
patients has also been published: Riley, G. F., Potosky, 
A. L., Lubitz, J. D., and Kessler, L. G.: "Medicare 
Payments from Diagnosis to Death for Elderly Cancer 
Patients by Stage at Diagnosis," Medical Care, 
Volume 33, pp. 828-841, 1995. The Health Care 
Financing Administration and the National Cancer 
Institute are also working jointly on a study to identify 
Medicare payments attributable specifically to cancer 
care. 



Studies examining the patterns and outcomes of care for 
several different cancer sites are in progress. 

IM-061 Patterns of Use and Payments 
for Disabled Medicaid Enrollees 

Funding: Intramural 

HCFA Project David K. Baugh 
Director: Division of Health Information and 

Outcomes 

Description: Within the Health Care Financing 
Administration, information is being sought about, the 
level of Medicaid payments, number of users (of specific 
services), and payments per user for subgroups of 
Medicaid disabled enrollees. It is important to understand 
utilization and payment variation for different groups 
within the Medicaid enrolled population. It is also 
important to understand the extent of variation for these 
groups across States and over time. A better 
understanding of the variations and the factors that cause 
(or correlate with, them will help in several areas: 

• Explaining trends in program spending growth. 

• Developing estimates of cost for disabled groups and 
disabling conditions. 

• Comparing Medicaid to other non-Medicaid 
populations. 

• Identifying special needs of Medicaid disabled 
subgroups. 

• Determining if important gaps exist in coverage and/or 
access. 

• Conducting comparisons for disabled individuals under 
fee-for-service versus managed care. 

• Assessing the equity proposed rates for prepaid plans. 

This work will use data from Medicaid Satistical 
Medicaid Research Files (SMRFs) to produce basic 
descriptive data on payments, users, and payments per 
user for selected Medicaid services by age group. While 
the data will be produced for all age groups, analyses will 
focus on disabled children. These data will provide us 
with initial benchmarks on utilization and payments for 
disabled subgroups that will be foundational. While these 
data will be useful on their own, they will lead to further 
development of hypotheses and analyses as we refine our 
understanding of the patterns we see. 

Status: The study is under review. 

IM-068 Persons With Acquired Immunodeficiency 
Syndrome in the Medicare Program 

Funding: Intramural 

HCFA Project Michael Kendix, Ph.D. 
Director: Division of Health Information and 

Outcomes 



Theme 3: Meeting the Needs of Vulnerable Populations 



183 



Description: Medicare claims data have been used to 
determine those Medicare beneficiaries with acquired 
immunodeficiency syndrome (AIDS). The data contain 
information on the use of services and program 
reimbursements for those services. This project will 
evaluate the use of Medicare program services for persons 
with AIDS. The study will identify health services 
utilization, access to care, and reimbursement patterns of 
persons with AIDS in the Medicare program. 

Status: The project is in the design phase. 

IM-071 Racial and Payer Differences in Infant 
Mortality in a National Sample of Preschool Children 

Funding: Intramural 

HCFA Project Rosemarie Hakim, Ph.D. 
Director: Division of Health Information and 

Outcomes 

Description: The project will use the National Maternal 
and Infant Health Survey database to analyze factors 
associated with infant mortality. Information on health 
insurance coverage, income, and use of prenatal services 
are available in this survey. Co-factors that vary between 
racial and income groups are available in this data set 
including race, barriers to care, and maternal factors will 
be used to predict infant mortality in each payer, race, and 
income group. 

Status: Analytical files are currently under review. 

IM-070 The Health of Poor Children 
in the United States 

Funding: Intramural 

HCFA Project Rosemarie Hakim, Ph.D. 
Director: Division of Health and Information 

Outcomes 

Description: The project will use the National Health and 
Nutrition Examination Survey III data set to describe 
health markers of children at various income levels. This 



is a cross-sectional, nationally representative study that 
can provide extensive information on the health status of 
Medicaid, uninsured, and privately insured children. The 
information available in this survey will allow for 
exploration of a large number of variables that influence 
the health of children, including insurance status, race, 
barriers to care, and use of health services. Health outcome 
indicators will include morbidity, including lead 
poisoning, anemia, injuries, and asthma, growth and 
development, and mortality. The denominator population 
will be U. S. population of children, 17 years of age and 
under. The information can be used to estimate the 
percentage of children using Medicaid services, and the 
extent of health problems among the insured and 
uninsured. 

Status: Analysis began in November 1996. 

IM-044 Utilization Patterns and Volume Stability at 
the Oncology Firm Level for Treatment of Medicare 
Beneficiaries with Cancer 



Funding: 
HCFA Project 
Director: 



Intramural 

Teresa DeCaro 

Division of Payment Systems 



Description: Patterns of care and volume stability at the 
physician organization level will be studied using per- 
capita measures of utilization for selected oncology 
services and for all Medicare services. The effect of the 
principal provider organization's characteristics, size, and 
case mix of oncology practice, and geographic location on 
per capita-costs will also be examined. These analyses 
will support the development of alternative service 
bundles and carve out payments for the care of Medicare 
cancer patients. The Medicare surveillance epidemiology 
and end result program database will be the principal 
source of data. 

Status: This project is in an early development phase. 



184 



Theme 3: Meeting the Needs of Vulnerable Populations 



Theme 4: Information to Improve Consumer Choice 
and Health Status 



Extramural 

95-057 Beneficiary Information, Education and 
Marketing Strategy 

Project No.: 500-95-0063 

Period: September 1995-March 1997 

Funding: $515,000 

Award: Small Business Contract 

Principal 

Investigator: Lisa Adato 

Awardee: Benova, Inc. 

1220 SW Morrison, Suite 700 

Portland, OR 97205 
HCFA Project Leslie M. Greenwald, Ph.D. 
Officer: Division of Delivery Systems and 

Financing 

Description: This contract, awarded in 1995 to Benova, 
Inc., will support the education and third-party 
enrollment activities envisioned for the planned Medicare 
Managed Care Competitive Pricing Demonstration. 
Specifically, the purposes of this project are to: 

• Develop an outreach strategy to reach all beneficiaries 
in the competitive bidding demonstration market area, 
and encourage them to take advantage of new 
opportunities to learn about the Medicare program and 
its options. 

• Develop a strategy for improved/innovative beneficiary 
education and understanding about health plan options 
under Medicare. 

• Develop specific prototype strategies and materials that 
will enable beneficiaries to choose effectively between 
new and different types of insurance plans in a third- 
party enrollment process. 

Thus far, the project has designed a range of outreach 
materials (including posters, models for public service 
announcements, and informational pamphlets) that will 
be used in the demonstration to encourage beneficiaries to 
participate in new educational opportunities sponsored by 
the Health Care Financing Administration under the 
demonstration. The project has also developed new 
prototype beneficiary handbooks and managed care plan/ 
Medigap plan comparison charts that use new formats to 
simplify information, and present it in a beneficiary- 
friendly way. These education and outreach materials 
were all refined through a beneficiary focus group and 
cognitive testing program; further testing and refinements 
are planned for early 1997. 

Status: Final deliverables will be completed in early 1997. 



94-099 Effects of Information and Consumer 
Knowledge on Choice of Health Plans 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



17-P-90348/5 

September 1994-March 1996 

$ 193,096 

Grant 

Francois Sainfort, Ph.D. 

Center for Health Systems Research 

and Analysis 

University of Wisconsin 

750 University Avenue 

Madison, WI 53706 

Judith A. Sangl, Sc.D. 

Division of Health Information and 

Outcomes 



Description: The primary purpose of this research 
involves studying how consumers make decisions about 
health care coverage and what role their knowledge about 
health plans plays in this decision process. A 
computerized-data collection system will be used to elicit 
consumer preference structures and to track the 
information search process, as well as record their actual 
plan choices under scenarios with differing amounts and 
types of information presented about each plan option. 
A pilot study based on a series of in-depth, face-to-face 
interviews with a small group of consumers will be 
conducted to test and refine the initial conceptual model 
and to design the data collection system. A sample of 
200 persons will be chosen from the study population of 
the employees of the State of Wisconsin who live within 
1-hour's driving time of Madison, Wisconsin. 

Status: The study found that in terms of: 
Problem perception: 

• Those who ranked choosing a health plan as the first or 
second most important decision spent more time on 
average accessing information than those who gave it 
lower importance. 

• Individuals perceiving the problem of choosing a health 
plan either as very difficult or very easy spent on 
average less time accessing information than subjects 
giving intermediate ratings of difficulty. 

Preference structure: 

• Almost two-thirds of participants changed their set of 
attributes over the experiment. 



Theme 4: Information to Improve Consumer Choice and Health Status 



185 



• The more information accessed, the more likely 
individuals were to change their attribute set between 
reviewing minimal information and more extensive 
information. 

• Four out often participants changed their rating of the 
relative importance of their attributes. 

• Those who chose the fee-for-service plan at time land 
time 2 placed a higher importance on plan rules with 
the most flexibility. 

• Individuals who chose the cheapest plan (the health 
maintenance organization) at time l(with minimal 
information) placed a higher importance on cost 
attributes. 

Choice: 

• There was a clear relationship between change in 
choice and amount and time of information access: 
people who changed their choice of plan after viewing 
the more detailed information looked at more screens 
and spent more time looking at information. 

• Those who chose the cheapest, poorest-quality plan at 
Choice 2 spent less time looking at information than 
those who chose other plans. 

• A model was able to correctly classify 85 percent of 
those who did or did not change their plan, with a 
measure of prediction success adjusted for scope and 
precision of 70 percent. 

Decision attitude: 

• There was a significant improvement in individuals' 
general attitude towards their decision from the first 
decision point to the second, i.e., from making a choice 
based on minimal information versus making a choice 
when far more information was available. 

• Similarly, the level of satisfaction with information and 
assistance was higher after access to the more detailed 
and complex information. 

The findings suggest a number of policy implications. 
Efforts are needed to increase the awareness of the 
importance of health plan choice to individuals. Just 
providing information, however, will not suffice. Specific 
efforts are needed to assist consumers in how to explore, 
understand, and use additional information. Efforts to 
develop structured decision assistance and support are 
needed since many people find choosing a health plan to 
be difficult. 

96-055 Evaluation of HCFA Online 



Project No.: 
Period: 
Funding: 
Award: 

Principal 
In estimator: 



500-95-0062/0002 

July 1996-September 1997 

$ 908,739 

Research and Demonstrations 

Task Order 

Gary Gaumer, Ph.D. 



A war dee: 



HCFA Project 
Officer: 



Abt Associates, Inc. 
55 Wheeler Street 
Cambridge, MA 02138 
Elizabeth Mauser, Ph.D. 
Division of Aging and Disability 



Description: HCFA Online is a comprehensive 
communications strategy designed to enhance the 
interaction between Health Care Financing 
Administration (HCFA) and its beneficiaries, providers 
and other partners. The purpose of this project is to 
develop evaluation designs to monitor and evaluate under 
a continuous quality improvement framework the projects 
included under HCFA Online, to provide technical 
assistance to the bureaus which are conducting the 
evaluation activities, and to develop outcome measures to 
evaluate HCFA's progress in improving its overall 
communications with their beneficiaries, providers, and 
other partners over time. 

Status: Currently, the evaluation designs are being 
developed, as well as outcome measures for HCFA's 
overall communication strategy. 

95-001 Evaluation of the Impact of Health Plan 
Report Cards on Consumer Knowledge, Attitudes, 
and Choice in a Managed Competition Setting 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



18-P-90601/5 

September 1995-December 1996 

$ 334,542 

Grant 

David J. Knutson 
Health Systems Research 
Institute for Research and Education 
Health System Minnesota 
3800 Park Nicollet Boulevard 
St. Louis Park, MN 55416 
Sherry A. Terrell, Ph.D. 
Division of Delivery Systems and 
Financing 



Description: The purpose of this study is to determine 
whether the dissemination of report card information 
about health care plans to consumers who choose health 
plans within a managed care competition framework will 
influence their knowledge of health plan characteristics, 
attitudes toward health plans, or choice of a health plan. 
The study population is employees of the State of 
Minnesota Group Insurance Program, in which employees 
select health plans during an annual fall open enrollment 
period. Some members of the program will receive report 
cards before they make their 1995 enrollment decisions, 
and a control group will not. Both groups will be surveyed 
before and after they make their health plan selections. 
Results will assist policymakers to determine how to 



1X6 



Theme 4: Information to Improve Consumer Choice and Health Status 



shape health plan report cards to best assist consumer 
decisionmaking. 

Status: Preliminary findings indicate that the report card 
does not influence employees' knowledge about the 
characteristics of the available health plans, but there is a 
highly significant difference in regard to an enrollee's 
knowledge about his or her specific plan. The group who 
received the report card had a significantly higher 
frequency of switching health plans in 1996 than the 
group who did not receive the report card. Among 
employees who did not switch plans, the group who 
received report cards was significantly more likely to have 
considered switching. Mixed results were found on 
attitudinal measures. Analysis is being completed on the 
influence of the report card on the decisionmaking 
process and the choice of plans. In another analysis that 
examined the helpfulness of the employee-sponsored 
report card compared with a community-wide report card 
disseminated through newspapers, more employees saw 
and read the employee sponsored report. When 
controlling for reading intensity, however, there was no 
difference in perceived helpfulness between the two 
methods of distribution. This finding has implications of 
how report card data might be more cost-effectively 
collected and disseminated by employers. The study was 
presented at a conference on consumer information and 
value sponsored by the Kaiser Family Foundation on 
October 29, 1996. Preliminary findings have been used 
for evaluations by both the Minnesota Health Data 
Institute and the State (Minnesota) Department of 
Employee Relations. An article, "Employee-Specific vs. 
Community-wide Report Cards: Is There a Difference?" is 
forth coming in the Health Care Financing Review. The 
final report will be completed by the end of the year. 

96-080 HCFA Online: Market Research 
for Beneficiaries 



Project No: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-95-0057TO02 

April 1996-September 1998 

$ 2,103,582 

Contract 

Kathryn Langwell 

Barents Group, LLC 

2001 M Street, NW. 

Washington, DC 20036 

Thomas Reilly, Ph.D. 

Division of Health Information and 

Outcomes 



Description: Health Care Financing Administration 
(HCFA) has implemented a market research program to 
provide ongoing assessment of the information needs of 
our beneficiaries. It will examine what information 



beneficiaries want and need from HCFA and how such 
information can best be communicated to them. HCFA's 
placing special emphasis on understanding the 
requirements of subgroups who may have special 
communication needs (e.g., vision-impaired or non- 
English-speaking beneficiaries). The research consists of 
multiple phases, including: conducting inventories of 
existing information on communication strategies 
relevant for beneficiaries, conducting focus groups to 
explore the information needs of beneficiaries, and 
collecting and analyzing survey data on information needs 
in beneficiary populations. This research will be used to 
help guide the development of HCFA's communication 
strategy. 

Status: The inventory and focus group work is under way, 
and the survey work is under review. 

96-005 HCFA Online: Market Research 
for Providers and Other Payers 

Project No.: 500-95-0057TO03 

Period: September 1996-August 1998 

Funding: $ 757,196 

Award: Task Order in a Basic Order Contract 

Principal 

Investigator: Kathryn Langwell 

Awardee: Barents Group, LLC 

(See page 202) 
HCFA Project Sherry A. Terrell, Ph.D. 
Officer: Division of Delivery Systems and 

Financing 

Description: HCFA Online is a comprehensive 
communications strategy designed to enhance interaction 
between the Health Care Financing Administration 
(HCFA) and its customers and partners and to ensure 
communications are efficient and cost effective. This 
specific market research task order is one component of 
the overall HCFA On-Line strategy. With a focus on 
providers and other partners (POPs), it will study 
systematically the information needs of providers, defined 
as physicians and hospitals and other partners, defined as 
managed-care plans, who participate in Medicare 
programs. Options are available to include additional 
providers, such as long-term-care and subacute-care 
providers, and Medicaid program information needs. For 
each group, answers to two questions will be sought — 
what information is needed from HCFA, and how best can 
the information be provided. The market research 
methodology will include three basic activities which are 
to — inventory existing information and communications 
strategies relevant for POPs, conduct focus groups with 
members or representatives of these groups, and survey 
POPs for information not available from the first two 
methods. Findings and recommendations will be used to 



Theme 4: Information to Improve Consumer Choice and Health Status 



187 



inform HCFA's customer communication strategy and to 
develop innovative service techniques and systems to 
better meet information needs. 

Status: The contractor has held the initial project kickoff 
meeting, begun the inventory task, and is organizing 
technical advisory panels of communications and subject 
matter experts. Products are expected quarterly over the 
life of the project. 

94-098 Information Needs for Consumer Choice 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-94-0047 

September 1994-July 1996 

$ 714,719 

Contract 

Barri Barrus, Ph.D. 

Research Triangle Institute 

P.O.Box 12194 

Research Triangle Park, NC 27709-2194 

Judith A. Sangl, Sc.D. 

Division of Health Information and 

Outcomes 



Description: This contract will examine the types of 
information consumers would find most useful in 
selecting health insurance plans, providers, and 
practitioners, and in making the chosen health care plan/ 
system work best for them. The study will determine how 
to present this type of information in a user-friendly way 
and will develop and test these consumer information 
approaches in given markets. The awardee will address 
consumer information issues and needs in both the 
current health care system and in proposals for health 
care system reform, especially as they relate to three broad 
consumer groups: Medicare beneficiaries, Medicaid 
beneficiaries, and the remaining U. S. population under 
65 years of age. Contract tasks include conducting up to 
24 focus groups, conducting 9 case studies of innovative 
consumer information projects, and developing and 
testing information materials in 2 different media for 
6 subgroups of the Medicare and Medicaid populations. 

Status: The focus groups and case studies have been 
completed. The results of the focus groups indicate that 
information needs varied across insurance groups. In 
general, Medicare beneficiaries were concerned with their 
access to current providers and the specialists of their 
choice, providers' communication skills, technical quality 
of care, and specific benefits relevant to their circum- 
stances. Beneficiaries were aware of cost, but it was rarely 
a primary decision factor. Many of those approaching 
Medicare eligibility were uninformed about the basic 
structure of Medicare and supplemental coverage. 
Medicaid eligibles were most interested in access to after- 
hours care, provider choice, waiting time, and providers' 



communication and interpersonal skills. 

Participants assessed the usefulness of three kinds of 
information for plan choice: consumer ratings, quality-of- 
care measures, and cost comparisons. Most responded 
favorably to samples of consumer ratings of plan 
performance. Differences in familiarity with surveys was 
apparent, with some participants requiring explanation of 
basic concepts of an independent survey, while others 
raised fairly sophisticated concerns regarding survey 
design and administration. Participant reactions to 
quality-of-care measures were more cautious. Many saw 
preventive care utilization as indicative of consumers' 
responsible actions rather than plan quality. Media 
preferences varied by insurance groups. Medicare 
beneficiaries consistently preferred a combination of 
individual or group presentations with printed reference 
material. Medicaid eligibles wanted group counseling 
sessions, similar to those they currently receive, but with 
the addition of detailed information on available plans. 
All participants said they preferred to receive information 
from unbiased, consumer-oriented sources. 

The case study component of this project served an 
important purpose, which was to learn about and from 
organizations across the country that were developing 
information to assist consumers in choosing a health plan 
and using the health care system. A total of 24 in-person 
interviews were conducted with a variety of organizations 
active in the consumer information field. Through the 
case studies, we identified a list of candidate performance 
measures, or quality indicators, for inclusion in our 
prototype materials that will be developed and tested on 
consumers. In addition, a list of potential formats/modes 
of communications was generated. 

Overall, traditional health plan information, such as 
premium amounts and benefit coverage, was the most 
common type of data included in the consumer materials 
reviewed. However, approximately one-half of the 
organizations also used selected survey-based satisfaction 
measures, as well as statistical performance measures 
based on administrative data. The printed report card was 
the most common format encountered; most report cards 
include a combination of text and graphics. Cost, space 
limitations, and level of expertise greatly influenced the 
choice of communication modes. On the whole, the 
materials developed by case-study organizations have not 
undergone rigorous evaluations. 

96-010 Medicare Coordinated Open Enrollment 

Project No.: 500-96-0024 

Period: September 1996-September 1997 

Funding: $ 459,970 

Award: Contract 



IX* 



Theme 4: Information to Improve Consumer Choice and Health Status 



Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Lisa Adato 

Benova, Inc. 

1220 SW Morrison, Suite 700 

Portland, OR 97205 

Leslie M. Greenwald, Ph.D. 

Division of Delivery Systems and 

Financing 



Description: A new contract was awarded to Benova, Inc., 
to assist the Health Care Financing Administration 
(HCFA) in the site development and implementation of 
the upcoming Medicare Competitive Pricing 
Demonstration. Under this contract, Benova will support 
HCFA's Office of Research and Demonstrations in 
preparing sites for the demonstration's implementation. 
Activities include: 

• Meeting with beneficiary advocacy groups, managed- 
care plans, and other local organizations. 

• Preparing analysis of site-specific features to assist in 
the final planning. 

• Adapting prototype beneficiary information materials to 
the specific features of the intended demonstration site. 

Under options to this contract, Benova will also conduct 
the actual implementation of the demonstration education 
and enrollment functions (including an extensive 
beneficiary outreach program, an expanded beneficiary 
education and information program, and a counseling and 
managed-care enrollment Call-Center) as HCFA's third- 
party agent. This current contract is related to an earlier 
Benova contract, in which prototype beneficiary outreach, 
information, and education materials and strategies were 
developed to support this demonstration. 

At the time of the contract award, no final sites for the 
Medicare Competitive Pricing Demonstration have been 
designated. The contract contains options for actual full 
implementation of the beneficiary outreach, education, 
and Call-Center counseling and enrollment broker 
activities to be conducted by Benova, if exercised 
by HCFA. 

Status: Demonstration site development activities are 
scheduled to take place during 1997. 

96-001 Research Data Assistance Center (ResDAC): 
Master Contract: University of Minnesota 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



500-96-0023 

September 1 996-September 

Task Order Contract 



997 



A. Marshall McBean, M.D. 
University of Minnesota 
Suite 201 

1100 Washington Avenue, South 
Minneapolis, MN 55415-1226 



HCFA Project Alan W. Bradt 

Officer: Division of Data Systems Resources 

Description: The Health Care Financing Administration 
(HCFA) created the Research Data Assistance Center 
(ResDAC) to assist new researchers develop familiarity 
and use of its massive databases for research on Medicare 
and Medicaid issues. ResDAC contract to the University 
of Minnesota includes a ResDAC consortium with Boston 
University, Dartmouth College, Georgetown University, 
and Fu Associates, Ltd. The initial contract is for 1 year 
with 4 option years. 

ResDAC will facilitate and expedite the use of HCFA data 
for research on Medicare and Medicaid by: 

• Serving as a focal point for researchers who are 
interested in pursuing studies on Medicare and 
Medicaid programs but lack the expertise to access or 
manipulate HCFA databases. 

• Serving as an educational and training center for 
researchers who have a need to use HCFA data. 

• Staffing a team of Medicare and Medicaid experts who 
are knowledgeable and experienced in both HCFA's 
data and its program history to assist researchers in 
understanding the data. 

• Improving researcher access to HCFA data by either 
providing designated data sets or assisting in 
developing data requests. 

This project will focus on outreach initiatives targeted to 
those unfamiliar with the use of large administrative data 
files and database training programs that are tailored to 
specific data applications. 

Status:This task order (TO) contract was awarded in 
September 1996. The awardee is able to compete for 
individual TO until September 2002. The first TO 
(awarded concurrently with the base contract) is for 
development and implementation of a User Request 
Control System and Outreach Plan. The overall funding 
amount for ResDAC contract no. 500-96-0023-0001, is 
$453,146.00. The individual TO project awarded under 
this contract is described in detail in identifier 96-062 of 
this edition of Active Projects Report. 

96-062 Research Data Assistance Center (ResDAC): 
Task Order: University of Minnesota 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



500-96-0023-0001 
September 1996-June 1997 
Task Order Contract 

A. Marshall McBean, MD 
University of Minnesota 
Suite 201 

1 100 Washington Ave, South 
Minneapolis, MN 55415-1226 



Theme 4: Information to Improve Consumer Choice and Health Status 



HCFA Project Alan W. Bradt 

Officer: Division of Data Systems Resources 

Description: The Health Care Financing Administration 
created the Research Data Assistance Center (ResDAC) to 
assist new researchers develop familiarity and use of its 
massive databases for research on Medicare and Medicaid 
issues. ResDAC contract to the University of Minnesota 
includes a ResDAC consortium with Boston University, 
Dartmouth College, Georgetown University, and Fu 
Associates, Ltd. The initial contract is for 1 year with 
4 option years. 

There are five activities for the first task: 

• Data expertise — ResDAC staff are to enhance their 
knowledge of the files designated for their use. 

• Availability of services — ResDAC staff are to develop 
an outreach plan to inform researchers of the files, 
services and training available through ResDAC. 

• Research data assistance steering committee — ResDAC 
staff will participate on the Steering committee. 

• Control system — ResDAC staff will develop and test a 
system to control requests for ResDAC services. 

• Charge-back and priority setting system — ResDAC is to 
develop a method for to set service priorities for use 
when resources are limited, and to ensure that data has 
been paid for before data is released. 

Status: This task order (TO) was awarded concurrently 
with the base contract on September 23, 1996. The con- 
tractor has nine months to complete the work specified 
under this task order. The funding for TO number 500- 
96-0023-0001 is $453,146.00. 

Intramural 

IM-031 Breast Cancer Treatment Initiative 

Funding: Intramural 

HCFA Project Joan L. Warren, Ph.D. 
Director: Division of Health Information and 

Outcomes 

Description: As part of the production of consumer 
information, the Health Care Financing Administration 
plans to use its administrative claims data in tandem with 
information from the National Cancer Institute to produce 
information aimed to help Medicare beneficiaries make 
more informed choices about available therapies for breast 
cancer. These data will be available to women with breast 
cancer and health care professionals. Data will be 
produced regarding the frequency of breast-conserving 
surgery for early-stage breast cancer and the frequency of 
use of radiation therapy following breast-conserving 
surgery. Data will be for all women with breast cancer as 
well as for specific age and race groups. 



Status: An updated linkage of data from the National 
Cancer Institute with Medicare data was completed in 
May 1996. Analysis is under way. 

IM-021 Database Development 

Funding: Intramural 

HCFA Project Sam McNeill, Wilson Kirby, and 

Daniel Babish 
Directors: Division of Data Systems and Resources 

Description: The daily operations of the Medicare and 
Medicaid programs involve the processing, adjudication, 
and payment of claims for health care services. As a 
result, extensive records are maintained on program 
participants, services, and payments. By linking, 
tabulating, sampling, and summarizing records from the 
administrative databases, extensive statistical files are 
produced. Data development entails the further 
development, aggregation, and linkage of these data to 
support research activities. This includes the development 
of these types of databases: 

• Benefit-specific, person-based. 

• Beneficiary cost-sharing. 

• Procedure-specific. 

• Morbidity-specific. 

• Benefit-specific database linked with provider 
databases. 

• Enrollment database linked with person-summary 
databases. 

• Provider of services. 

• SAS and statistical Medicaid research databases. 

The availability of person-specific and procedure-specific 
data make these databases useful for epidemiological 
research initiatives and a myriad of other special studies. 

Status: This is an ongoing, intramural research project. 
Most of the databases described are maintained on a 
calendar-year basis. Databases containing calendar year 
1995 data are available, and those containing calendar- 
year 1996 data should be available by mid- 1997. 

IM-030 Influenza Immunization Initiative 

Funding: Intramural 

HCFA Project David K. Baugh 
Director: Division of Health Information and 

Outcomes 

Description: As part of the Consumer Information 
Strategy, the Health Care Financing Administration is 
seeking to increase the number of influenza 
immunizations among Medicare beneficiaries to reach the 
year 2000 goal of a 60-percent influenza immunization 
rate for all persons 65 years of age or older. The influenza 



90 



Theme 4: Information to Improve Consumer Choice and Health Status 



initiative involves a public awareness campaign, outreach 
activities among several peer review organizations, and 
the production and dissemination of Medicare influenza 
immunization rates. Influenza immunization rates were 
developed from all claims paid by the Medicare program 
for Part B Medicare beneficiaries 65 years of age or older 
who received immunizations in the fee-for-service sector 
between September 1. and December 31, 1994. Rates were 
prepared for the Nation, States, and counties, as well as 
by gender, age, and race. It is hoped that the 
dissemination of the data on Medicare paid 
immunizations will help increase awareness of the 
Medicare-influenza immunization benefit and will assist 
in achieving a 60-percent immunization rate for the 
elderly Medicare population. 

Status: The data book. 1994 Influenza Immunizations 
Paid for by Medicare, is currently being disseminated. 
Production of the data book for 1995 is under way. 

IM-032 Mammography Utilization Initiative 

Funding: Intramural 

HCFA Project David K. Baugh 
Director: Division of Health Information and 

Outcomes 

Description: Under the Consumer Information Strategy, 
the Health Care Financing Administration (HCFA) is 
seeking to increase the use of mammography services by 
elderly female beneficiaries. Mammography is 
particularly valuable in reducing breast cancer deaths 
among older women, who experience the highest 
incidence and mortality from breast cancer. HCFA data 
and national surveys indicate that biennial mammography 
use is far below the 60-percent figure proposed as a 
national health objective for the year 2000. 

A year-long campaign to increase awareness and use of 
the Medicare mammography benefit was inaugurated 
May 1, 1995, by Hillary Rodham Clinton. A featured 
component of the campaign was a data book prepared by 
Office of Research and Demonstrations and the Bureau of 
Data Management and Strategy that contained Medicare 
age- and race-specific mammography use rates at the 
State and county level. Biennial rates for 1992-93 were 
reported, as well as 1993 annual rates. This 
mammography data book was disseminated to public 
health and cancer organizations to help target outreach 
activities to areas with particularly low utilization. 

Continued analysis of mammography use is anticipated on 
an annual basis, to help monitor the effectiveness of 
interventions to increase mammography use. Analyses of 
1994 and 1995 Medicare data have been initiated, and 
involve Central and Resional Office research staff. 



IM-020 Program Information Inquiries 

Funding: Intramural 

HCFA Project Roger E. Keene 

Director: Division of Data Systems and Resources 

Description: The primary objective of the Program 
Information Inquiries project is to provide the Health Care 
Financing Administration (HCFA), other Federal 
Government agencies, and the entire health care 
community with current and historical Medicare and 
Medicaid data in response to health care information 
requests. Medicare and Medicaid data and related 
information are available on enrollment, service 
utilization, program payments, providers of services, 
morbidity, procedures, diagnosis-related groups, and 
beneficiary cost sharing. 

Status: This ongoing intramural project derives data from 
an extensive inventory of HCFA statistical and analytical 
files, which are a byproduct of the daily administrative 
operations of the Medicare and Medicaid programs 
involving the processing, adjudication, and payment of 
claims for covered health care services. Program-wide 
data generally are available within 9 months after the 
close of the year and are available on request. 

IM-033 Prostate Disease Information Initiative 



Funding: 
HCFA Project 
Director: 



Intramural 

Maria A. Friedman 

Dissemination Staff 



Description: As part of its consumer information strategy, 
the Health Care Financing Administration (HCFA) was 
considering initiatives to help beneficiaries make more 
informed choices about treatment options for prostate 
disease. This includes educating beneficiaries and 
providers about the full range of therapeutic options 
available for treatment of prostate-related problems. These 
are common in elderly men, and their treatment costs 
Medicare millions of dollars annually. Some prostate 
conditions are cancerous. In fact, prostate cancer is the 
most common form of cancer among American men. 
Surgical treatment for prostate cancer is on the rise. Yet, 
this course is controversial and its effectiveness has been 
questioned in relation to non-surgical options. Other 
prostate conditions are benign. Half of all men 60 years of 
age or over have swelling of the prostate called benign 
prostatic hyperplasia (BPH). By 80 years of age, one man 
in four will require treatment for it. However, BPH and 
some of its treatments have major side effects that 
significantly affect beneficiaries' quality of life. For 
example, men with BPH often experience frequent 
urination or, conversely, difficulty in postponing 



Theme 4: Information to Improve Consumer Choice and Health Status 



191 



urination. Surgical treatment of BPH can cause urinary Status: The outreach portions of this initiative have been 

incontinence and impotence. As a result, patients need to taken over and put on hold by HCFA's Health Status 

have information available to make an informed treatment Improvement Team, which has the responsibility for 

choice. Providers need to be educated about treatment HCFA's consumer information initiatives. Research 

options and trained to work with consumers to help them continue in the Office of Research and Demonstrations to 

better understand available options. better understand treatment patterns and outcomes. 



192 Theme 4: Information to Improve Consumer Choice and Health Status 



Master Contracts and Research Centers 



94-095 Medicare Ambulatory and Coordinated 
Care Demonstration Projects: Master Contract: 
Brandeis University 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



500-94-0043 

September 1 994-September 

Contract 



997 



HCFA Project 
Officer: 



Stanley Wallack, Ph.D. 

Brandeis University 

Heller Graduate School 

Institute for Health Policy 

415 South Street 

P.O. Box 91 10 

Waltham, MA 02254-9110 

Samuel L. Brown 

Division of Aging and Disability 



Description: This master contract provides for the design, 
development, conduct, and evaluation of Medicare 
ambulatory and coordinated care demonstration projects. 
The intent of these demonstration projects is to obtain 
information in a timely manner for program and policy 
consideration. 

Status: This master contract was awarded in September 
1994. This awardee is able to compete for individual 
delivery orders (DO) for 12 months. The first DO 
(awarded concurrently with the base contract) is for 
general management, which includes monthly reports, 
meeting with the Federal Government on request, and 
responding to requests for issue papers. The funding 
amount for the first management DO, 500-94-0043DO01, 
is $ 10,530. The individual DO project awarded under this 
master contract is described in detail in the following 
section of this edition of the Active Projects Report. 

Theme 2: Improving Health Care Financing 
and Delivery Mechanisms: Current Programs 
and New Models 

• Medicare End Stage Renal Disease Capitation 
Demonstration, 500-94-0043DO02. 

92-087 Research Centers: Master Contract: 
Health Economics Research, Inc. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 



500-92-0020 

August 1992-August 1996 

Contract 

Janet B. Mitchell, Ph.D. 



Awardee: 



HCFA Project 
Officer: 



Health Economics Research, Inc. 

300 Fifth Avenue, 6th Floor 

Waltham, MA 02154 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This master contract provides for the design, 
development, and conduct of research and demonstration 
projects. The intent of these projects is to obtain 
information in a timely manner for program and policy 
consideration. 

Status: This master contract was awarded in August 1992. 
The first delivery order (DO) (awarded concurrently with 
the base contract) is for general management, which 
includes submitting monthly reports, meeting with the 
Federal Government on request, and responding to 
requests for issue papers. The overall funding amount for 
the management DO, 500-92-0020DO01, is $38,91 1. The 
individual DO projects awarded under the master contract 
which still remain open, are described in detail in the 
following sections of this edition of Active Projects Report 

Theme 1 : Monitoring and Evaluating Health 
System Performance: Access, Quality, Program 
Efficiency and Costs 

• Estimating Mammography Utilization by Elderly 
Medicare Women for Whom the Health Care Financing 
Administration Does Not Receive Administrative 
Claims, 500-92-0020DO1 1. 

• Understanding Properties of the UPIN for Claims-Based 
Research, 500-92-0020DO14. 

Theme 2: Improving Health Care Financing and 
Delivery Mechanisms: Current Programs and 
New Models 

• Second Revision of Medicare Geographic Practice Cost 
Index, 500-92-0020DO13. 

92-088 Research Centers: Master Contract: 
Lewin/VHI, Inc. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



500-92-0021 

August 1992-August 1996 

Contract 

Allen Dobson, Ph.D. 
Lewin/VHI, Inc. 
9300 Lee Highway, Suite 500 
Fairfax, VA 22031-1207 



Master Contracts and Research Centers 



193 



HCFA Project 
Officer: 



Leslie A. Mangels 
Financial. Administrative and 
Procurement Staff 



Description: This master contract provides for the design, 
development, and conduct of research and demonstration 
projects. The intent of these projects is to obtain 
information in a timely manner for program and policy 
consideration. 

Status: This master contract was awarded in August 1992. 
The first delivery order (DO) (awarded concurrently with 
the base contract) is for general management, which 
includes submitting monthly reports, meeting with the 
Federal Government on request, and responding to 
requests for issue papers. The overall funding amount for 
the management DO, 500-92-002 1DO01, is $24,044. The 
individual DO project awarded under the master contract, 
which still remains open, is described in detail in the 
following section of this edition of Active Projects Report. 

Theme 3: Meeting the Needs of 
Vulnerable Populations 

• Study of the Natural History of End Stage Renal Disease 
in Persons with Diabetes, 500-92-002 1DO04. 

92-090 Research Centers: 

Master Contract: Rand Corporation 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



500-92-0023 
August 1992-June 
Contract 



!996 



HCFA Project 
Officer: 



Grace M. Carter, Ph.D. 

Rand Corporation 

Health Sciences Program 

1 700 Main Street 

P.O. Box 2138 

Santa Monica, CA 90407-2138 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This master contract provided for the design, 
development, and conduct of research and demonstration 
projects. The intent of these projects is to obtain 
information in a timely manner for program and policy 
consideration. 

Status: This master contract was awarded in August 1992. 
The first delivery order (DO) (awarded concurrently with 
the base contract) is for general management, which 
includes submitting monthly reports, meeting with the 



Federal Government on request, and responding to requests 
for issue papers. The overall funding amount for the 
management DO, 500-92-0023DO01, is $64,244. 
The individual DO projects awarded under the master 
contract are described in detail in the following section of 
this edition of Active Projects Report. 

Theme 2: Improving Health Care Financing and 
Delivery Mechanisms: Current Programs and 
New Models 

• Evaluation of Case Classification Systems and a Design 
of a Prospective Payment Model for Inpatient 
Rehabilitation, 500-92-0023DO1 1. 

92-089 Research Centers: Master Contract: 
University of Minnesota 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-92-0022 

August 1992-December 1996 

Contract 

Jon Christianson, Ph.D. 

University of Minnesota 

Institute for Health Services Research 

School of Public Health, Box 729 

420 Delaware Street, SE. 

Minneapolis, MN 55455-0392 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This master contract provides for the design, 
development, and conduct of research and demonstration 
projects. The intent of these projects is to obtain 
information in a timely manner for program and policy 
consideration. 

Status: This master contract was awarded in August 1992. 
The first delivery order (DO) (awarded concurrently with 
the base contract) is for general management, which 
includes submitting monthly reports, meeting with the 
Federal Government on request, and responding to 
requests for issue papers. The overall funding amount for 
the management DO, 500-92-0022DO01, is $43,150. The 
individual DO project awarded under the master contract, 
which is still open, is described in detail in the following 
section of this edition of Active Projects Report. 

Theme 3: Meeting the Needs of 
Vulnerable Populations 

• Multistate Analysis of Utilization, Expenditures, and 
Access to Care for Persons with Acquired 
Immunodeficiency Syndrome, 500-92-0022DO04. 



194 



Master Contracts and Research Centers 



Task Order Contracts 



Extramural 

96-022 Long-Term-Care Task Order Contract: 
Abt Associates, Inc. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0003 
May 1996- April 
Contract 



1997 



Robert Schmitz 

Abt Associates, Inc. 

55 Wheeler Street 

Cambridge, MA 02138 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of long-term-care 
research and demonstration projects. The intent of these 
projects is to obtain information in a timely manner for 
program and policy consideration. 

Status: This task order contract was awarded in May 
1996. This awardee is able to compete for individual 
task orders (TO) until April 2001. The first TO 
(awarded concurrently with the base contract) is for 
general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-96-0003TO01, is $6,103, to date. In addition, 
Abt Associates has been awarded the following tasks: 

Theme 1: Monitoring and Evaluating Health 
System Performance: Access, Quality, Program 
Efficiency and Costs 

• Evaluation of the District of Columbia's 
Demonstration Project: Managed Care System for 
Disabled and Special Needs Children, 
500-96-0003/TO No. 3. 

Theme 2: Improving Health Care Financing 
and Delivery Mechanisms: Current Programs 
and New Models 

• Case-Mix Adjustment for a National Home Health 
Prospective Payment System, 500-96-0003/TO No. 2. 



96-023 Long-Term-Care Task Order Contract: 
Center for Health Policy Research 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0004 

May 1996-April 1997 

Contract 

Peter Shaughnessy, Ph.D. 

Center for Health Policy Research 

1355 South Colorado Boulevard 

Denver, CO 80222 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of long-term-care 
research and demonstration projects. The intent of these 
projects is to obtain information in a timely manner for 
program and policy consideration. 

Status: This task order contract was awarded in 
May 1996. This awardee is able to compete for 
individual task orders (TO) until April 2001. The first 
TO (awarded concurrently with the base contract) is for 
general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-96-0004TO01, is $6,035, to date. In addition, 
Abt Associates has been awarded the following task, 
Program for All-inclusive Care for the Elderly (PACE) 
Quality Assurance, 500-96-0004TO No. 2. 

96-024 Long-Term-Care Task Order Contract: 
Lewin/VHI, Inc. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0005 

May 1996-April 1997 

Contract 

Lisa Alecxih 

Lewin/VHI, Inc. 

9302 Lee Highway, Suite 500 

Fairfax, VA 22031-1214 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of long-term-care 



Task Order Contracts 



195 



research and demonstration projects. The intent of these 
projects is to obtain information in a timely manner for 
program and policy consideration. 

Status: This task order contract was awarded in May 
1996. This awardee is able to compete for individual 
task orders (TO) until April 2001. The first TO 
(awarded concurrently with the base contract) is for 
general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-96-0005TO1, is $5,279, to date. This awardee has 
not been awarded any additional task orders. 

96-026 Long-Term-Care Task Order Contract: 
Michigan Public Health Institute 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0007 

May 1996-April 1997 

Contract 

William Weissert 

Michigan Public Health Institute 

2465 Woodlake Circle 

Okemos, WI 48864 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of long-term-care 
research and demonstration projects. The intent of these 
projects is to obtain information in a timely manner for 
program and policy consideration. 

Status: This task order contract was awarded in May 
1996. This awardee is able to compete for individual 
task orders (TO) until April 2001. The first TO 
(awarded concurrently with the base contract) is for 
general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-96-0007TO1, is $5,059, to date. This awardee has 
not been awarded any additional task orders. 

96-029 Long-Term-Care Task Order Contract: 
Research Triangle Institute 



Project No.: 


500-96-0010 


Period: 


May 1996-May 1997 


Award: 


Contract 


Principal 




Investigator: 


Catherine Hawes 



Awardee: 



HCFA Project 
Officer: 



Research Triangle Institute 

3040 Cornwallis Road 

P.O.Box 12194 

Research Triangle Park, NC 27709 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of long-term-care 
research and demonstration projects. The intent of these 
projects is to obtain information in a timely manner for 
program and policy consideration. 

Status: This task order contract was awarded in May 
1996. This awardee is able to compete for individual 
task orders (TO) until April 2001. The first TO 
(awarded concurrently with the base contract) is for 
general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-96-00 10TO1, is $5,052, to date. This awardee has 
not been awarded any additional task orders. 

96-025 Long-Term-Care Task Order Contract: 
MedStat Group 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0006 
May 1996-April 
Contract 



997 



Beth Jackson 

MedStat Group 

4401 Connecticut Avenue, NW. 

Washington, DC 20008 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of long-term-care 
research and demonstration projects. The intent of these 
projects is to obtain information in a timely manner for 
program and policy consideration. 

Status: This task order contract was awarded in May 
1996. This awardee is able to compete for individual 
task orders (TO) until April 2001. The first TO 
(awarded concurrently with the base contract) is for 
general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-96-0006TO1, is $4,164, to date. This awardee has 
not been awarded any additional task orders. 



196 



Task Order Contracts 



96-028 Long-Term-Care Task Order Contract: 
Rand Corporation 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500 : 96-0009 

May 1996-June 1997 

Contract 

Joan Buchanan, Ph.D. 

Rand Corporation 

1700 Main Street 

Santa Monica, CA 90407-2138 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of managed-care 
research and demonstration projects. The intent of these 
projects is to obtain information in a timely manner for 
program and policy consideration. 

Status: This task order contract was awarded in May 
1996. This awardee is able to compete for individual 
task orders (TOs) until April 2001. The first TO 
(awarded concurrently with the base contract) is for 
general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-96-0009TO1, is S5,595, to date. Rand has not been 
awarded any additional task orders. 

96-027 Long-Term-Care Task Order Contract: 
University of Minnesota 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0008 

May 1996- April 1997 

Contract 

Robert L. Kane, M.D. 
University of Minnesota 
420 Delaware Street, SE. 
Minneapolis, MN 55455-0392 
Leslie A. Mangels 
Financial, Administrative, and 
Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of long-term-care 
research and demonstration projects. The intent of these 
projects is to obtain information in a timely manner for 
program and policy consideration. 

Status: This task order contract was awarded in 
May 1996. This awardee is able to compete for 
individual task orders (TOs) management, which 
includes submitting monthly reports, meeting with the 
Federal Government on request, and responding to 

Task Order Contracts 



requests for issue papers. The overall funding amount 
for the management TO, 500-96-008TO1, is $7,829, to 
date. This awardee has not been awarded any 
additional task orders. 

95-038 Managed-Care Research and Demonstration 
Task Order Contract: Barents Group, LLC 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-95-0046 

September 1995-September 1997 

Contract 

Darwin Johnson 

Barents Group, LLC 

2001 M Street, NW. 

Washington, DC 20036 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of managed-care 
research and demonstration projects. The intent of these 
projects is to obtain information in a timely manner for 
program and policy consideration. 

Status: This task order contract was awarded in 
September 1995. This awardee is able to compete for 
individual task orders (TO) until September 2000. The 
first TO (awarded concurrently with the base contract) is 
for general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-95-0046TO1, is $18,821, to date. This awardee has 
not been awarded any additional task orders. 

95-039 Managed-Care Research and Demonstration 
Task Order Contract: Brandeis University 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-95-0052 

September 1995-September 1997 

Contract 

Joel M. Cohen 
Brandeis University 
Institute for Health Policy 
415 South Street 
Waltham, MA 02254-91 10 
Leslie A. Mangels 
Financial, Administrative, and 
Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of managed-care 
research and demonstration projects. The intent of these 



197 



projects is to obtain information in a timely manner for 
program and policy consideration. 

Status: This task order contract was awarded in 
September 1995. This awardee is able to compete for 
individual task orders (TO) until September 2000. The 
first TO (awarded concurrently with the base contract) is 
for general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-95-0052TO1, is $1 1,417, to date. This awardee has 
not been awarded any additional task orders. 

95-040 Managed-Care Research and 
Demonstration Task Order Contract: 
Health Economics Research, Inc. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-95-0048 

September 1995-September 

Contract 



997 



Janet B. Mitchell, Ph.D. 

Health Economics Research, Inc. 

300 Fifth Avenue, 6th Floor 

Waltham, MA 02154 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of managed-care 
research and demonstration projects. The intent of these 
projects is to obtain information in a timely manner for 
program and policy consideration. 

Status: This task order contract was awarded in 
September 1995. This awardee is able to compete for 
individual task orders (TO) until September 2000. The 
first TO (awarded concurrently with the base contract) is 
for general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-95-0048TO1, is 510,963, to date. The individual 
TO projects awarded under this contract are described in 
detail in the following sections of this edition of Active 
Projects Report. 

Theme 1: Monitoring and Evaluating 
Health System Performance: Access, Quality, 
Program Efficiency and Costs 

• Access in Managed-Care Plans, 
500-95-0048TO2. 



Theme 2: Improving Health Care Financing 
Delivery Mechanisms: Current Programs and 
New Models 

• Evaluation of Group- Specific Volume Performance 
Standards Demonstration, 500-95-0048TO4. 

• Refinements to Medicare DCG Risk Adjustment 
Models, 500-95-0048TO3. 

95-041 Managed-Care Research and Demonstration 
Task Order Contract: Lewin/VHI, Inc. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-95-0049 

September 1995-September 1997 

Contract 

David Stapleton 

Lewin/VHI, Inc. 

9302 Lee Highway, Suite 500 

Fairfax, VA 22031-1207 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of managed-care 
research and demonstration projects. The intent of these 
projects is to obtain information in a timely manner for 
program and policy consideration. 

Status: This task order contract was awarded in 
September 1995. This awardee is able to compete for 
individual task orders (TO) until September 2000. The 
first TO (awarded concurrently with the base contract) is 
for general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-95-0049TO1, is $10,738, to date. This awardee has 
not been awarded any additional task orders. 

95-042 Managed-Care Research and Demonstration 
Task Order Contract: Mathematica Policy Research 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-95-0047 

September 1995-September 1997 

Contract 

Don F. Lara 

Mathematica Policy Research 

101 Morgan Lane 

Plainsboro, NJ 08536 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of managed-care 



198 



Task Order Contracts 



research and demonstration projects. The intent of these 
projects is to obtain information in a timely manner for 
program and policy consideration. 

Status: This task order contract was awarded in 
September 1995. This awardee is able to compete for 
individual task orders (TO) until September 2000. The 
first TO (awarded concurrently with the base contract) is 
for general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-95-0047TO1, is S 5,592. The individual TO 
projects awarded under this task order contract are 
described in detail in the following section of this 
edition of Active Projects Report. 

Theme 2: Improving Health Care Financing 
and Delivery Mechanisms: Current Programs and 
New Models 

• Evaluation of the HMO Outlier Demonstration, 
500-95-0047TO02. 

95-043 Managed-Care Research and Demonstration 
Task Order Contract: MedStat Group 



95-044 Managed-Care Research and Demonstration 
Task Order Contract: Rand Corporation 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-95-0050 

September 1995-September 1997 

Contract 

William Marder 

MedStat Group 

4401 Connecticut Avenue, NW. 

Washington, DC 20008 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of managed-care 
research and demonstration projects. The intent of these 
projects is to obtain information in a timely manner for 
program and policy consideration. 

Status: This task order contract was awarded in 
September 1995. This awardee is able to compete for 
individual task orders (TO) until September 2000. The 
first TO (awarded concurrently with the base contract) is 
for general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-95-0050TO1, is $18,650, to date. This awardee has 
not been awarded any additional task orders. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-95-0064 

September 1995-September 

Contract 



997 



Grace M. Carter, Ph.D. 

Rand Corporation 

1700 Main Street 

Santa Monica, CA 90407-2138 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of managed-care 
research and demonstration projects. The intent of these 
projects is to obtain information in a timely manner for 
program and policy consideration. 

Status: This task order contract was awarded in 
September 1995. This awardee is able to compete for 
individual task orders (TOs) until September 2000. The 
first TO (awarded concurrently with the base contract) is 
for general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-95-0054TO1, is $13,120, to date. 

Rand was awarded the following TO project: 
Preparation and Analysis of Department of Defense 
(DOD) and Medicare Data in Support of DOD/Medicare 
Subvention Demonstration, 500-95-0054TO2. 

95-045 Managed-Care Research and Demonstration 
Task Order Contract: University of Minnesota 

Project No.: 500-95-0053 

Period: September 1995-September 1997 

Award: Contract 

Principal 

Investigator: Richard L. Wright 

Awardee: University of Minnesota 

420 Delaware Street, SE. 

Minneapolis, MN 55455-0392 
HCFA Project Leslie A. Mangels 
Officer: Financial, Administrative and 

Procurement Staff 

Description: This task order contract provides for the 
design, development, and conduct of managed-care 
research and demonstration projects. The intent of these 
projects is to obtain information in a timely manner for 
program and policy consideration. 



Task Order Contracts 



199 



Status: This task order contract was awarded in 
September 1995. This awardee is able to compete for 
individual task orders (TOs) until September 2000. The 
first TO (awarded concurrently with the base contract) is 
for general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-95-0053TO1, is $13,736, to date. The University of 
Minnesota was awarded an additional TO during fiscal 
year 1996, Disenrollment and Selection Experience in 
the Medicare HMO Risk Program: 1990-94, 
500-95-0053TO2. 

96-030 Maternal and Child Health 

Task Order Contract: Abt Associates, Inc. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0012 

June 1996-May 1997 

Contract 

Carol Irvin, Ph.D. 

Abt Associates, Inc. 

55 Wheeler Street 

Cambridge, MA 02138 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of research and 
demonstration projects related to maternal and child 
health. The intent of these projects is to obtain 
information in a timely manner for program and policy 
consideration. 

Status: This task order contract was awarded in 
June 1996. This awardee is able to compete for 
individual task orders (TO) until May 2001. The first 
TO (awarded concurrently with the base contract) is for 
general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-96-00 12TO01, is $4,1 17, to date. This awardee has 
not been awarded any additional task orders. 

96-032 Maternal and Child Health Task Order 
Contract: Health Economics Research, Inc. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 



500-96-0014 

June 1996-May 1997 

Contract 

Margo L. Rosenbach, Ph.D. 



Awardee: 



HCFA Project 
Officer: 



Health Economics Research, Inc. 

300 Fifth Avenue, 6th Floor 

Waltham, MA 02154 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of research and 
demonstration projects related to maternal and child 
health. The intent of these projects is to obtain 
information in a timely manner for program and policy 
consideration. 

Status: This task order contract was awarded in June 
1996. This awardee is able to compete for individual 
task orders (TO) until September 2001. The first TO 
(awarded concurrently with the base contract) is for 
general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-96-00 14TO01, is $ 4,989, to date. This awardee has 
not been awarded any additional task orders. 

96-036 Maternal and Child Health 
Task Order Contract: Lewin/VHI, Inc. 

Project No.: 500-96-0015 

Period: June 1996-May 1997 

Award: Contract 

Principal 

Investigator: Susanna Ginsburg 

Awardee: Lewin/VHI, Inc. 

9302 Lee Highway, Suite 500 
Fairfax, VA 22031-1214 

HCFA Project Leslie A. Mangels 

Officer: Financial, Administrative, and 

Procurement Staff 

Description: This task order contract provides for the 
design, development, and conduct of research and 
demonstration projects related to maternal and child 
health. The intent of these projects is to obtain 
information in a timely manner for program and policy 
consideration. 

Status: This task order contract was awarded in June 
1996. This awardee is able to compete for individual 
task orders (TO) until September 2001. The first TO 
(awarded concurrently with the base contract) is for 
general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-96-00 15T01, is $6,207, to date. This awardee has 
not been awarded any additional task orders. 



200 



Task Order Contracts 



96-033 Maternal and Child Health Task Order 
Contract: Mathematica Policy Research 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0016 

June 1996-May 1997 

Contract 

Don F. Lara 

Mathematica Policy Research 

101 Morgan Lane 

Plainsboro, NJ 08536 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of research and 
demonstration projects related to maternal and child 
health. The intent of these projects is to obtain 
information in a timely manner for program and policy 
consideration. 

Status: This task order contract was awarded in June 
1996. This awardee is able to compete for individual 
task orders (TO) until September 2001. The first TO 
(awarded concurrently with the base contract) is for 
general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-96-00 16T01, is $6,095, to date. This awardee has 
not been awarded any additional TOs. 

96-035 Maternal and Child Health Task Order 
Contract: Research Triangle Institute 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0018 

June 1996-May 1997 

Contract 

Norma Gavin 

Research Triangle Institute 

3040 Cornwallis Road 

P.O.Box 12194 

Research Triangle Park, NC 27709 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of research and 
demonstration projects related to maternal and child 
health. The intent of these projects is to obtain 
information in a timely manner for program and policy 
consideration. 

Status: This task order contract was awarded in June 
1996. This awardee is able to compete for individual 



task orders (TO) until September 2001. The first TO 
(awarded concurrently with the base contract) is for 
general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-96-00 18T01, is $4,572, to date. This awardee has 
not been awarded any additional task orders. 

96-034 Maternal and Child Health 
Task Order Contract: Rand Corporation 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-96-0017 

June 1996-May 1997 

Contract 

Grace M. Carter and 

Stephen H. Long, Ph.D. 

Rand Corporation 

1700 Main Street 

Santa Monica, CA 90407-2138 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of managed-care 
research and demonstration projects related to maternal 
and child health. The intent of these projects is to obtain 
information in a timely manner for program and policy 
consideration. 

Status: This task order contract was awarded in June 
1996. This awardee is able to compete for individual 
task orders (TOs) until September 2001. The first TO 
(awarded concurrently with the base contract) is for 
general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-96-00 17T01, is $6,880, to date. Rand was awarded 
the following TO project, Improving Outcomes for 
Low-Income Pregnant Women: Effects of Medicaid 
Eligibility and Alternative Delivery Systems, 
500-96-00 17T02. 

96-03 1 Maternal and Child Health Task Order 
Contract: University of Alabama at Birmingham 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 



500-96-0013 

June 1996-May 1997 

Contract 

Janet Bronstein, Ph.D. 



Task Order Contracts 



201 



Awardee: 



HCFA Project 
Officer: 



University of Alabama at 

Birmingham 

701 20th Street, South, AB-1170 

Birmingham, AL 35294-0111 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of research and 
demonstration projects related to maternal and child 
health. The intent of these projects is to obtain 
information in a timely manner for program and policy 
consideration. 

Status: This task order contract was awarded in June 
1996. This awardee is able to compete for individual 
task orders (TO) until May 2001. The first TO (awarded 
concurrently with the base contract) is for general 
management, which includes submitting monthly 
reports, meeting with the Federal Government on 
request, and responding to requests for issue papers. The 
overall funding amount for the management TO, 500- 
96-00 13TO01, is $6,319, to date. One additional TO has 
been awarded to the University, Comparison of 
Pharmaceutical Quality of Care for Pediatric Asthma 
Across Medicaid and Insured Populations, 
500-96-00 13T02. 

95-030 Research and Demonstration 
Task Order Contract: Abt Associates, Inc. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-95-0062 

September 1995-September 

Contract 



997 



David Kidder, Ph.D. 

Abt Associates, Inc. 

55 Wheeler Street 

Cambridge, MA 02138-1168 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of research and 
demonstration projects. The intent of these projects is to 
obtain information in a timely manner for program and 
policy consideration. 

Status: This task order contract was awarded in 
September 1995. This awardee is able to compete for 
individual task orders (TO) until September 2000. The 
first TO (awarded concurrently with the base contract) is 
for genera] management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 



The overall funding amount for the management TO, 
500-95-0062TO01, is $10,772, to date. In addition, Abt 
Associates has been awarded the task, Evaluation of 
HCFA Online, during fiscal year 1996. 

95-031 Research and Demonstration Task Order 
Contract: Barents Group, LLC 



Project No.: 
Period: 

Award: 
Principal 
Investigator: 
Awardee: 



HCFA Project 
Officer: 



500-95-0057 

September 1995-September 1997 

Contract 

Darwin Johnson 

Barents Group, LLC 

2001 M Street, NW. 

Washington, DC 20036 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of research and 
demonstration projects. The intent of these projects is to 
obtain information in a timely manner for program and 
policy consideration. 

Status: This task order contract was awarded in 
September 1995. This awardee is able to compete for 
individual task orders (TO) until September 2000. The 
first TO (awarded concurrently with the base contract) is 
for general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-95-0057TO01, is $18,821 to date. Barents has been 
awarded two additional TOs during fiscal year 1996 — 
TO No. 2, HCFA Online: Market Research for 
Beneficiaries, and TO No. 3, HCFA On-Line: Market 
Research for Providers. 

95-032 Research and Demonstration 
Task Order Contract: Brandeis University 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-95-0060 

September 1995-September 1997 

Contract 

Joel M. Cohen 
Brandeis University 
Institute for Health Policy 
415 South Street 
Waltham, MA 02254-9110 
Leslie A. Mangels 
Financial, Administrative, and 
Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of research and 



202 



Task Order Contracts 



demonstration projects. The intent of these projects is to 
obtain information in a timely manner for program and 
policy consideration. 

Status: This task order contract was awarded in 
September 1995. This awardee is able to compete for 
individual task orders (TO) until September 2000. The 
first TO (awarded concurrently with the base contract) is 
for general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-95-0060TO01, is $12,913, to date. This awardee 
has not been awarded any additional task orders. 

95-033 Research and Demonstration Task Order 
Contract: Health Economics Research, Inc. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-95-0058 

September 1995-September 1997 

Contract 

Janet B. Mitchell, Ph.D. 

Health Economics Research, Inc. 

300 Fifth Avenue, 6th Floor 

Waltham, MA 02154 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of research and 
demonstration projects. The intent of these projects is to 
obtain information in a timely manner for program and 
policy consideration. 

Status: This task order contract was awarded in 
September 1995. This awardee is able to compete for 
individual task orders (TO) until September 2000. The 
first TO (awarded concurrently with the base contract) is 
for general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-95-0058TO01, is $12,338, to date. This awardee 
has not been awarded any additional task orders. 

95-034 Research and Demonstration 
Task Order Contract: Lewin/VHI, Inc. 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



500-95-0059 

September 1995-September 1997 

Contract 

Allen Dobson, Ph.D. 
Lewin/VHI, Inc. 
9302 Lee Highway, Suite 500 
Fairfax, VA 22031-1214 



HCFA Project Leslie A. Mangels 
Officer: Financial, Administrative, and 

Procurement Staff 

Description: This task order contract provides for the 
design, development, and conduct of research and 
demonstration projects. The intent of these projects is to 
obtain information in a timely manner for program and 
policy consideration. 

Status: This task order contract was awarded in 
September 1995. This awardee is able to compete for 
individual task orders (TO) until September 2000. The 
first TO (awarded concurrently with the base contract) is 
for general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-95-0059TO01, is $9,955, to date. In addition, 
Lewin/VHI has been awarded the task, Study on 
Effectiveness of Current End Stage Renal Disease 
Survey and Certification; and Potential of Integrating 
Private Accreditation and Nonregulatory Incentives. 
This TO was developed by the Health Standards and 
Quality Bureau. 

95-035 Research and Demonstration 
Task Order Contract: Rand Corporation 



Project No.: 

Period: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



500-95-0056 

September 1 995-September 

Contract 



997 



Richard L. Wright 

Rand Corporation 

1700 Main Street 

P.O. Box 2138 

Santa Monica, CA 90407-2138 

Leslie A. Mangels 

Financial, Administrative, and 

Procurement Staff 



Description: This task order contract provides for the 
design, development, and conduct of research and 
demonstration projects. The intent of these projects is to 
obtain information in a timely manner for program and 
policy consideration. 

Status: This task order contract was awarded in 
September 1995. This awardee is able to compete for 
individual task orders (TO) until September 2000. The 
first TO (awarded concurrently with the base contract) is 
for general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-95-0056TO01, is $13,790, to date. Additional TO 



Task Order Contracts 



203 



projects awarded under this task order contract are: 

Theme 1 : Monitoring and Evaluating Health 
System Performance: Access, Quality, Program 
Efficiency and Costs 

• Development of a Comprehensive Monitoring and 
Evaluation Initiative for HCFA Programs, 
500-95-0056TO02. 

95-037 Research and Demonstration 
Task Order Contract: Urban Institute 

Project No.: 500-95-0055 

Period: September 1995-September 1997 

Award: Contract 

Principal 

Investigator: Stephen Zuckerman, Ph.D. 

Awardee: Urban Institute 

2100 M Street, NW. 

Washington, DC 20037 
HCFA Project Leslie A. Mangels 
Officer: Financial, Administrative, and 

Procurement Staff 

Description: This task order contract provides for the 
design, development, and conduct of research and 
demonstration projects. The intent of these projects is to 
obtain information in a timely manner for program and 
policy consideration. 

Status: This task order contract was awarded in 
September 1995. This awardee is able to compete for 
individual task orders (TO) until September 2000. The 
first TO (awarded concurrently with the base contract) is 
for general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-95-0055TO1, is $15,048, to date. In addition, 
Urban Institute has been awarded the task, Evaluation of 
Municipal Health Service Program Demonstration. 



95-036 Research and Demonstration Task Order 
Contract: University of Wisconsin 

Project No.: 500-95-0061 

Period: September 1995-September 1997 

Award: Contract 

Principal 

Investigator: David Zimmerman Ph.D. 

Awardee: University of Wisconsin 

750 University Avenue 
Madison, WI 53706-1490 

HCFA Project Leslie A. Mangels 

Officer: Financial, Administrative, and 

Procurement Staff 

Description: This task order contract provides for the 
design, development, and conduct of research and 
demonstration projects. The intent of these projects is to 
obtain information in a timely manner for program and 
policy consideration. 

Status: This task order contract was awarded in 
September 1995. This awardee is able to compete for 
individual task orders (TO) until September 2000. The 
first TO (awarded concurrently with the base contract) is 
for general management, which includes submitting 
monthly reports, meeting with the Federal Government 
on request, and responding to requests for issue papers. 
The overall funding amount for the management TO, 
500-95-0061 TOO 1, is $13,178. This awardee has not 
been awarded any additional task orders. 



204 



Task Order Contracts 



Small Business Innovation Research 



95-079 Automated Control for Imaging Modalities 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandates: 



97-P-08089/6-01 
June 1995-June 1996 
$ 86,311 
Grant 

Robert Murry 

BRIT Systems 

1402 Corinth Street, Suite 221 

Dallas, TX 75215 

Cheryl D. Sample 

Financial, Administrative, and 

Procurement Staff 

Small Business Innovation Development 
Act of 1982 (Public Law 97-219; as 
amended by the Small Business 
Innovative Research Program, 
Extension, Public Law 99-443) 

Description: The purpose of this project is to develop 
computer programs for automating the testing of medical 
diagnostic imaging equipment. The programs will run on 
the vast majority of existing medical image computer 
networks that many radiology departments already have. 
This development will provide testing methods for most 
medical image quality parameters that are much faster 
and less expensive than the largely manual alternative 
methods. 

Status: Phase I (development) was completed and the final 
report has been received. Because the Small Business 
Innovation Research program sponsors the development 
of commercially viable products, it carefully protects the 
developer's intellectual property. Detailed information on 
this project and the product may be obtained from the 
awardee. 

95-084 Computerizing the 
Reports of Interpretive Tests 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



97-P-08 106/3-0 
June 1995-June 1996 
$ 50,000 
Grant 

John G. Sotos 

MVBS Inc. 

4401 Roland Avenue, Suite 414 

Baltimore, MD 21210 

Cheryl D. Sample 

Financial, Administrative, and 

Procurement Staff 



Mandates: Small Business Innovation Development 

Act of 1982 (Public Law 97-219; as 
amended by the Small Business 
Innovation Research Program, 
Extension, Public Law 99-443) 

Description: The grantee will develop and test a system 
for computerizing the reports of two medical tests 
involving cognitively complex domains, echocardio- 
graphy, and upper gastrointestinal endoscopy. 

Status: Phase I (development) was completed. Because the 
Small Business Innovation Research program sponsors 
the development of commercially viable products, it 
carefully protects the developer's intellectual property. 
Detailed information on this project and the product can 
be obtained from the awardee. 

95-077 Conversion 2000 

Project No.: 97-P-08 117/3-01 

Period: June 1995-June 1996 

Funding: $ 48,620 

Award: Grant 

Principal 

Investigator: Willard Lee Anderson, II 

Awardee: Anderson Consulting and Computer 

Services, Inc. 

1 20 Woodland Farms Road 

Pittsburgh, PA 15238 
HCFA Project Cheryl D. Sample 
Officer: Financial, Administrative, and 

Procurement Staff 

Mandates: Small Business Innovation Development 

Act of 1982 (Public Law 97-219; as 
amended by the Small Business 
Innovation Research Program, 
Extension, Public Law 99-443) 

Description: The purpose of this project is to define a 
system for health care management that ensures the best 
opportunity for providing a high quality of care for 
Medicare and Medicaid recipients and simultaneously 
provides a framework to establish mechanisms for 
efficient medical management using currently available 
technology. 

Status: Phase I (development) was completed and the 
final report has been received; however, Phase II (testing 
and gathering) was not funded. Because the Small 
Business Innovation Research program sponsors the 
development of commercially viable products, it carefully 



Small Business Innovation Research 



205 



protects the developer's intellectual property. Detailed 
information on this project and the product can be 
obtained from the awardee. 

95-080 Design of Specialized Protocol Software to 
Monitor Health Care and Case-Management Data 

Project No.: 97-P-081 12/8-01 

Period: June 1995-June 1996 

Funding: $ 50,000 (Phase I) 

SI 27,640 (Phase II) 
Award: Grant 

Principal 

Investigator: Jerry H. Kogan 
Awardee: CK Computer Consultants 

210 North Higgins, Suite 334 

Missoula, MT 59802 
HCFA Project Carl S. Hackerman 
Officer: Financial, Administrative, and 

Procurement Staff 

Mandates: Small Business Innovation Development 

Act of 1982 (Public Law 97-219; as 
amended by the Small Business 
Innovation Research Program, 
Extension, Public Law 99-443) 

Description: This project addresses the need to develop 
products that help all participants in health care to assess 
and monitor the quality and level of care furnished to 
patients. Computer software designed to monitor health 
care data can provide vital assistance to this end. 

Status: Phase I (development) has been completed. The 
project is currently in Phase II (testing and data 
gathering). Because the Small Business Innovation 
Research program sponsors the development of com- 
mercially viable products, it carefully protects the 
developer's intellectual property. Detailed information on 
this project and the product can be obtained from the 
awardee. 

95-081 Interactive Computerized Program to 
Assist Medicare Beneficiaries in Evaluating 
Medigap Options 



HCFA Project 
Officer: 



Mandates: 



Project No.: 


97-P-08 133/3-01 


Period: 


June 1995-June 1996 


Funding: 


$ 46,450 (Phase I) 




$156,150 (Phase II) 


Award: 


Grant 


Principal 




Investigator: 


Leonard Greenberg 


Awardee: 


LBD Associates 




203 North Aspen Avenue 




Sterling, VA 20164 



Carl S. Hackerman 
Financial, Administrative, and 
Procurement Staff 

Small Business Innovation Development 
Act of 1982 (Public Law 97-219; as 
amended by the Small Business 
Innovation Research Program, 
Extension, Public Law 99-443) 



Description: This project proposes a program for 
evaluating Medicare supplemental insurance options. The 
program will be designed to operate interactively based on 
minimal input from the beneficiary and maximum use of 
archived information concerning January 31, 1996 
Medicare fee schedules, deductibles, copayments, and the 
like. A prototype program will be developed in this phase 
and at least partially tested. 

Status: Phase I (development) was completed and the final 
report has been received. The project is currently in 
Phase II (testing and data gathering). Because the Small 
Business Innovation Research program sponsors the 
development of commercially viable products, it carefully 
protects the developer's intellectual property. Detailed 
information on this project and the product can be 
obtained from the awardee. 

95-078 Investigation System for 
Health Care Fraud and Abuse 

Project No.: 97-P-08 124/3 

Period: June 1995-June 1996 

Funding: $ 46,650 (Phase I) 

$145,045 (Phase II) 
Award: Grant 

Principal 

Investigator: Robert D. Smith 
Awardee: Anthem Corporation 

12020 Sunrise Valley Drive 

Reston, VA 22091 
HCFA Project Carl S. Hackerman 
Officer: Financial, Administrative, and 

Procurement Staff 

Mandates: Small Business Innovative Development 

Act of 1982 (Public Law 97-219; as 
amended by the Small Business 
Innovation Research Program, 
Extension, Public Law 99-443) 

Description: The purpose of this project is to evaluate the 
feasibility of using artificial intelligence software to assist 
in the identification, investigation, and prosecution of 
health care fraud and abuse. The technical approach to be 
employed calls for the selection of a subset of fraud and 



206 



Small Business Innovation Research 



abuse schemes related to home health care and the 
identification of indicators associated with these schemes. 

Status: Phase I (development) has been completed and the 
final report received. The project is currently in Phase II 
(testing and gathering). Because the Small Business 
Innovation Research program sponsors the development 
of commercially viable products, it carefully protects the 
developer's intellectual property. Any detailed 
information on this project and the product must be 
obtained from the awardee. 

95-083 Medical Claims Analysis Using Artificial 
Neural Network Pattern Recognition Methods 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandates: 



97-P-0809 1/4-01 
June 1995-June 1996 
$ 55,844 
Grant 

Steven M. Epstein 

Med-AI, Inc. 

602 Courtland Street, Suite 400 

Orlando, FL 32804 

Cheryl D. Sample 

Financial, Administrative, and 

Procurement Staff 

Small Business Innovative Development 
Act of 1982 (Public Law 97-219; as 
amended by the Small Business 
Innovation Research Program, 
Extension, Public Law 99-443) 



Description: In this project, the ability to recognize 
suitability patterns in Medicare and other medical claims 
data will be demonstrated by employing artificial neural 
network pattern recognition methods. The project will 
identify patterns such as whether the procedure is 
appropriate for the reported diagnosis, whether the patient 
demographics are appropriate for the reported diagnosis, 
or whether the charges claimed are reasonable for the 
intervention and treatments reported. 

Status: Phase I (development) was completed and a final 
report has been received. Because the Small Business 
Innovation Research program sponsors the development 
of commercially viable products, it carefully protects the 
developer's intellectual property. Detailed information on 
this project and the product can be obtained from the 
awardee. 

95-072 Online Information, Counseling, and Assistance 
Program Reporting and Telecommunications System 



Funding: 


$ 64,913 


Award: 


Grant 


Principal 




Investigator: 


Sara Derenge 


Awardee: 


Technovation Training, Inc. 




3458 Brantford Road 




Toledo, OH 43606-2416 


HCFA Project 


Leslie A. Mangels 


Officer: 


Financial, Administrative, and 




Procurement Staff 


Mandate: 


Small Business Innovation De\ 



Act of 1982 (Public Law 97-219, as 
amended by the Small Business 
Innovation Research Program, 
Extension, Public Law 99-443) 

Description: This project will examine the feasibility of 
developing the following three services: 

• Counseling. 

• Sself-assessment instrument. 

• Related publications on quality aspects of Medicare 
managed care. 

These products/activities would provide the means for 
Medicare beneficiaries in the Washington, D.C., area to 
make informed decisions when choosing a managed-care 
plan. 

Status: This project is in the development stage. 

95-053 Patient Record System for Managing and 
Monitoring Health Care Delivery and Outcome 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandate: 



Project No.: 
Period: 



97-P-08086/5-01 
June 1995-June 1996 



97-P-08 134/4-01 
June 1995-June 1996 
$ 50,000 
Grant 

Frank Hadlock 
Metalingual Systems, Inc. 
2750 Shipley Church Rd. 
Cookeville, TX 38501 
Carl S. Hackerman 
Financial, Administrative, and 
Procurement Staff 

Small Business Innovation Development 
Act of 1982 (Public Law 97-219, as 
amended by Public Law 99-443) 



Description: This project will ultimately structure a 
comprehensive medical information system based on 
efforts to standardize computer patient records and on 
technology developed for credit-card-size devices. 



Small Business Innovation Research 



207 



Status: The project has been completed phase 1 of the 
grant. The final report is currently under review. 

95-054 Preparing Medicare Consumers for 
Selecting and Utilizing Managed-Care Plans 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandates: 



97-P-08 114/3-01 
June 1995-June 1996 
S 49,920 
Grant 

Sarah Gotbaum 

USHC Developmental Corporation 

1331 H Street, NW., Suite 500 

Washington, DC 20005 

Carl S. Hackerman 

Financial, Administrative, and 

Procurement Staff 

Small Business Innovation Development 
Act of 1982 (Public Law 97-219, as 
amended by Public Law 99-443) 

Description: The project will examine the feasibility of 
developing: 

• Counseling. 

• Self-assessment instruments. 

• Related publications on quality of Medicare managed 
care to allow beneficiaries to make informed decisions 
when selecting a managed-care plan. 

Status: The project completed phase 1 of the grant. The 
final report has been received and is currently under 
review. 

95-071 Voice-Assisted Data Entry and 
Management for Home Health Agencies 



Project No.: 


97-P-08 120/6-01 


Period: 


June 1995-June 1996 


Funding: 


$ 45,477 


Award: 


Grant 


Principal 




Investigator: 


Ken A. Barnett 


Awardee: 


Technology International, Inc. 




429 West Airline Highway, Suite S 




LaPlace, LA 70068 


HCFA Project 


Leslie A. Mangels 


Officer: 


Financial, Administrative, and 




Procurement Staff 



Mandate: Small Business Innovation Development 

Act of 1982 (Public Law 97-219, as 
amended by Public Law 99-443) 

Description: This project will design a prototype system 
(Ptolemy) as a first step in developing a computer-based 
patient record. The purpose of this Phase I project is to: 

• Extend the prototype into a functional, collaborative 
reporting system for echocardiography and upper 
gastrointestinal endoscopy services. 

• Test the degree to which it meets requirements of the 
system. 

Status: This project is in the development phase. 

95-082 Wide Area Networking of 
Computerized Patient Records 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Mandates: 



97-P-08099/9-01 
June 1995-June 1996 
$ 50,000 
Grant 

Bruce S. Orisek 

MIS, Inc. 

Dominican Professional Building 

1505 Soquel Drive 

Santa Cruz, CA 95065 

Cheryl D. Sample 

Financial, Administrative, and 

Procurement Staff 

Small Business Innovative Development 
Act of 1982 (Public Law 97-219; as 
amended by the Small Business 
Innovation Research Program, 
Extension, Public Law 99-443) 



Description: The major objective of this project is the 
further development and clinical trial of computer-based 
patient records within a wide area network called MIS/ 
Work Comp System, a product that will diminish and, in 
many cases, negate the need for utilization review. 

Status: Phase I (development) has been completed. 
Because the Small Business Innovation Research program 
sponsors the development of commercially viable 
products, it carefully protects the developer's intellectual 
property. Detailed information on this project can be 
obtained from the awardee. 



208 



Small Business Innovation Research 



Dissertation Fellowship Grants 



96-016 A Longitudinal Study of the 
Determinants and Outcomes of Drug 
Utilization by People with HIV Disease 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



30-P-90669/5-01 
March 1996-March 
S 21,117 
Grant 



1997 



Scott Smith 

University of Michigan 
College of Pharmacy 
1028 College of Pharmacy 
Ann Arbor, MI 48109 
Carl S. Hackerman 
Financial, Administrative and 
Procurement Staff 



Description: Funding provided for completion of 
dissertation. 

Status: Work has begun. 

96-020 An Evaluation of the Connecticut 
General Assistance Managed Behavioral 
Health Care Pilot Program 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



30-P-90662/1-01 
March 1996-March 1997 
S 21,600 
Grant 

Neil Thakur 

Yale School of Medicine 

60 College Street 

New Haven, CT 06520 

Carl S. Hackerman 

Financial, Administrative, and 

Procurement Staff 



Description: Funding provided for completion of 
dissertation. 

Status: Work has begun. 

96-012 Do the Elderly Respond Differently Than the 
Non-Elderly to Price and Quality Information When 
Choosing Between Health Plans? 



Project No: 


30-P-90670/5-01 


Period: 


March 1996-March 1997 


Funding: 


$21,128 


Award: 


Grant 



Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



Dennis Scanlon 
University of Michigan 
1420 Washington Heights 
Ann Arbor, MI 48109 
Carl S. Hackerman 
Financial, Administrative, and 
Procurement Staff 



Description: Funding provided for completion of 
dissertation. 

Status: Work has begun. 

96-019 Effects of State Medicaid Policies on the 
Risk of Nursing Home Admission and Length of Stay 



Project No.: 


30-P-90675/2-01 


Period: 


March 1996-March 1997 


Funding: 


$ 21,600 


Award: 


Grant 


Principal 




Investigator: 


Haruko Nogochi 


Awardee: 


City University of New York 




33 West 42nd Street 




New York, NY 10036 


HCFA Project 


Carl S. Hackerman 


Officer: 


Financial, Administrative, and 




Procurement Staff 



Description: Funding provided for completion of 
dissertation. 

Status: Work has begun. 

96-017 Functional Diversity in Health Service 
Provision: Community Mental Health Center Choice 



Project No: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



30-P-90684/5-01 
March 1996-March 1997 
$21,600 
Grant 

Eloine Plaut 
University of Chicago 
5801 South Ellis Ave. 
Chicago, IL 60637 
Carl S. Hackerman 
Financial, Administrative, 
Procurement Staff 



and 



Description: Funding provided for completion of 
dissertation. 

Status: Work has begun. 



Dissertation Fellowship Grants 



209 



96-013 Kidney Allocation to Patients on the 
Transplant Waiting Lists: A Comprehensive Study 



96-021 Organizational Double Agents: Agency and 
Institutionalism in Medical Group Governance 



Project No: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



30-P-90673/01 

March 1996-March 1997 

S 20,097 

Grant 

Stefanos Zenios 

Massachusetts Institute of Technology 

Room E40- 14977 Massachusetts Ave 

Cambridge, MA 02139 

Carl S. Hackerman 

Financial, Administrative, and 

Procurement Staff 



Description: Funding provided for completion of 
dissertation. 

Status: Work has begun. 

96-018 Modeling Case Manager's Care Planning 
Decisions for Community Dwelling Disabled Elders 
in Medicaid HCBS Waiver Programs 



Project No: 


30-P-90671/5-01 


Period: 


March 1996-March 1997 


Funding: 


$21,600 


Award: 


Grant 


Pricipal 




Investigator: 


Howard Degenholtz 


Awardee: 


University of Minnesota 




420 Delaware Street 




Minneapolis, MN 55455 


HCFA Project 


Carl S. Hackerman 


Officer: 


Financial, Administrative, and 




Procurement Staff 



Description: Funding provided for completion of 
dissertation. 

Status: Work has begun. 



Project No.: 

Period: 

Funding: 

Award: 

Principal 

Investigator: 

Awardee: 



HCFA Project 
Officer: 



30-P-90679/9-01 
March 1996-March 1997 
$21,311 
Grant 

Heather Elms 
University of California 
405 Higard Avenue 
Los Angeles, CA 90095 
Carl S. Hackerman 
Financial, Administrative, and 
Procurement Staff 



Description: Funding provided for completion of 
dissertation. 

Status: Work has begun. 

96-015 Prior Mammography Use: Does It Explain 
Black/White Differences in Breast Cancer Outcomes 



Project: 


30-P-90665/6-01 


Period: 


March 1996-March 1997 


Funding: 


$21,600 


Award: 


Grant 


Principal 




Investigator: 


Ellen McCarthy 


Awardee: 


Tulane University 




1430 Tulane Avenue 




New Orleans, LA 701 12 


HCFA Project 


Carl S. Hackerman 


Officer: 


Financial, Administrative, and 




Procurement Staff 



Description: Funding provided for completion of 
dissertation. 

Status: Work has begun. 



210 



Dissertation Fellowship Grants 



Topical Index 



A 

AAPCC 31, 37, 86 

Access 1, 8, 15, 32, 33, 34, 

103, 104, 106, 116, 125, 126, 138, 163, 174, 176, 

181, 182, 183, 189 

ADP 2 

Adult day care 27, 145, 146, 148, 

149, 150, 151, 152, 153, 154, 155, 156, 157, 158 

Adult day health care 59 

AFDC 72, 91, 93, 94, 96, 

100, 122, 128, 129, 130, 139, 142, 143, 146, 147, 

166, 175, 178, 179, 180 

African- American women 177 

AIDS 141, 183 

All-payer systems 38, 83 

Alternative payment 

arrangements 71 

Alzheimer's disease 112 

Ambulatory care 39, 42, 44, 46, 47, 

57, 65, 176, 193 

Ambulatory care group 37, 49 

Ambulatory patient groups 39 

Annual Survey of Hospitals 6 

Asset test 123 

Assistive equipment 174 

Asthma 6 

B 

Barriers 104, 176 

Beneficiary satisfaction 31 

Beno v. Shalala 94 

Birth outcomes 136 

Boren Amendment 17 

Bundled payment 39, 75, 77 

C 

California capitation 

case management 53 

Capitated payment 79, 80, 81, 82, 128, 

Capitation 5, 1 1, 38, 42, 48, 49, 

50, 51, 52, 54, 64, 65, 76, 78, 79, 80, 86, 89, 97, 
98, 129, 132, 145, 146, 148, 149, 150, 151, 152, 
153, 154, 155, 156, 157, 158, 162, 165, 166, 
169, 175, 193 



Cardiovascular procedures 67, 176 

Caregivers 150 

Carve out 49 

Case management 42, 43, 44, 52, 54, 

57, 58, 89, 97, 98, 161 

Case-mix measurement 12,41, 48,55,61 

Cataract 66, 67, 72 

Catastrophic cost 39, 136, 137, 94 

Categorical eligibility 

requirement 133 

Center of Excellence 67, 68, 69,70 

Certificate of need 17 

Chargeback 189 

Chemical dependence 147 

Children 6, 95,99, 136, 140, 

181, 183 

CHOICES 58, 71 

Chronic impairments 127 

Claims data 27,28, 191 

Clinical breast examination 177 

Clinical conditions 16 

Cognitive impairment 126 

Communications 186 

Community-based care 14, 18, 28, 46, 77, 

97,98, 104, 112, 124, 143, 169, 177 
Community integrated 

service network 171 

Comorbidity 138 

Competition 66 

Congestive heart failure 43 

Consumer-directed care 161 

Consumer information 186, 187 

Consumer surveys 186 

Continuous quality 

improvement 46, 77, 186 

Conversion factor 87 

Coordinated care 65, 148 

Coronary artery bypass graft .... 68, 69, 70 

Cost-based reimbursement 56, 57 

Cost effectiveness 55, 103 

Cost health maintenance 

organization 55 

Cost of care 8, 18 

Cultural research 181 

Customer service 187 



Topical Index 



211 



D 

Data 26, 103, 141, 151, 

174, 182, 189, 190, 191 

Delivery 170, 171, 172, 174 

Dementia 1 12 

Demonstrations 64, 65, 66, 193 

Dental 99, 139 

Developmental disabilities 98, 104, 141, 162, 

167 

DRGs 24, 75, 77, 

DCGs 37, 125 

Dialysis 104, 105, 106, 107, 

125, 136, 168, 181 

Diarrheal disease treatment 146 

Disability 6, 11, 17, 79,95, 

108, 121, 124, 127, 128, 140, 159, 183 

Discharge planning 174 

Disease prevention and 

health promotion 120 

Disenrollment 31 

Disparities 182 

Distribution of nursing 

home costs 22 

Dually entitled 16,59,61, 148, 169, 

Durable medical equipment 50, 174 

E 

Econometric cost functions 60 

Economic status 107 

Education 107, 141, 176, 177, 

Elderly 14, 17,24, 107, 126, 

169 
Employment Development 

Plan 130 

Empowerment zone/enterprise 

community 143 

Encounter data 1, 56, 88, 169 

EPSDT 3, 6, 99, 181 

ESRD 52, 53, 54, 67, 104, 

105, 107, 125, 132, 136, 168, 173, 181, 182, 193 

Enrollment 3,6,20, 191 

Episode payment 83, 162 

EACH 11, 108, 109, 110, 

1 11 

Estate recovery 41 

Ethnicity 138 

Evaluation 56, 57, 58, 98, 1 13, 

1 15. 1 16. 1 18. 160. 167, 186 



Expanded care in 

nursinghomes 78 

Expenditures 3, 6, 20, 98, 124 

Experience rating 37 

F 

Facility deficient data 27 

Family development program.... 143 

Family planning services 7, 13 

FQHCs 121 

Financial eligibility limits 133 

Financing 87, 170, 171, 172, 

174, 

Formal, informal care 5 

Frail elderly 128, 151 

Full Employment Program 130 

G 

Generic drugs 29 

GAF 38 

Geographic cost variation 50 

GPCI 41,82 

Geriatrics 80,174 

GME 84,87 

Group-specific volume 

performance standards 44, 56 

H 

HBCUs 103, 124, 141, 

174, 181 

HCFA Online 186, 187 

Health care cooperative 171 

Health care prepayment plan 55 

Health insurance 29, 87, 134 

Health insurance and reform, 

employer-based 40 

Health insurance and reform, 

State-sponsored 40 

Health insurance, supplemental . 10,31,51 
HMOs 31, 37, 38, 49, 50, 

53, 54, 55, 64, 65, 66, 71, 79, 86, 193, 144, 

197,204 
Health professional 

shortage area 113 

Health reform demonstration 131 

Health services research 124, 181, 182 

Health services utilization 183 



212 



Topical Index 



Health status 3 

High-risk 119 

Home and community- 
based care 4 

Home and nursing home care .... 5 

Home health 5, 6, 14, 18, 24, 25, 

28, 38, 41, 42, 46, 56, 57, 62, 75, 83, 92, 97, 
98, 137, 176 

Home health aides 14 

Homeless families stabilization . 125 

Hospice 95 

Hospital 6, 11, 137, 163, 187 

Hospital costs 15, 16,30 

Hospital, limited service 11, 108, 109, 

110, 111 

Hospital market factors 15, 16 

Hospital outpatient department . 12, 46, 47, 61 

Hospital payment methods 83 

Hospital performance 12 

Hospital use reduction 174 

Hospital utilization 16 

I 

ICF/MR 160 

Immunizations 99, 146 

Income 181, 182, 184 

Influenza 2 

Injuries 181 

Inpatient 6 

Institutional care 104, 138 

Integrated care 3, 18, 80, 81, 82, 

129, 145, 146, 148, 149, 150, 151, 152, 153, 154, 
155, 157, 158, 165, 166, 169, 170, 171, 174 
International data 16 

J 

Job opportunities and 

basic skills 91 

K 

Kellogg Foundation 171 

L 

Localities (phyician payment) ... 38 

Long-term care 14, 17, 18,26,43, 

64, 80, 81, 82, 104, 127, 165, 166, 169, 176, 

195, 196, 197 



Longitudinal analysis 1 

Los Angeles 118 

Low-income 139 

M 

Malpractice 41, 82 

Mammography screening 177 

Managed care 1, 11, 13,42,48,49, 

50, 53, 54, 58, 59, 71, 78, 79, 80, 82, 85, 86, 89, 
92, 115, 123, 124, 128, 129, 139, 144, 147, 162, 
166, 167, 169, 180, 186, 187 

Managed competition model 122 

Market-based 66 

Medicaid 3, 6, 8, 13, 23, 41, 

44, 49, 54, 72, 75, 79, 87, 91, 92, 93, 94, 96, 98, 
99, 100, 106, 115, 116, 119, 121, 122, 123, 124, 
125, 127, 129, 133, 134, 139, 141, 142, 143, 
147, 166, 174, 175, 178, 179, 180, 181, 183 

Medicaid and children 3, 20 

Medicaid coordinated care 132 

Medicaid eligibility 7, 126 

Medicaid "estate planning" 170 

Medicaid extension 116, 117 

Medicaid: home care 4 

Medical malpractice premiums . 87 

Medicaid managed care 105, 113 

Medicaid 1915(b) waivers 112 

Medicaid reimbursement rates .. 17 

MSIS 132 

MAF: rural, frontier area 135 

Medical record review 27 

Medical savings accounts 87 

Medical spending growth 29 

Medically underserved area 113 

Medicare beneficiaries 12 

Medicare Beneficiary Health 

Status Registry 1, 3 

Medicare beneficiary 

information 185, 188 

Medicare carriers 38 

Medicare Cost Reports 30 

MCBS 3, 15, 20, 28, 51, 

54, 86, 92, 127 

MEI 41,82 

Medicare expenditure 87 

Medicare fee schedule 15, 28, 41, 45, 46, 

84, 88 
MFSA 38 



Topical Index 



213 



Medicare prevention 

demonstrations 120 

Medicare SELECT 10, 31 

Medigap insurance 10, 31 

Mental health 95, 119, 138, 144, 

147. 163, 167, 175, 176 
Mental retardation and 

developmental disabilities ... 95, 140 

Minimum data set 151 

Minority beneficiaries 182, 184 

Monitoring 5, 8 

Moral hazard 87 

N 

National Black Women's 

Help Project 146 

National Health Interview 

Survey 34 

National Health Interview Survey 

Disability Supplement 140 

National Medical Expenditures 

Survey 124 

National Monthly Hospital 

Panel Survey 6 

Negotiated price 66, 67, 72 

NEHIS 2 

Network 11, 108, 109, 110, 

111. 170, 171, 172, 174 

Non-elderly 173 

Nurse 42, 97, 98 

Nurse management 5,42, 57 

Nursing facilities 59, 62, 63, 72, 73, 

74, 84, 85 

Nursing home acute care 78 

Nursing home beds 25 

Nursing home cost 22 

Nursing-home eligible 59 

Nursing home reimbursement ... 26 
Nursinghomes 16, 17, 27, 95, 136, 

137 

O 

OhioCare 144 

Operation 103 

Oral rehydration therapy 146 

Organizational form 28 

Outcome measures 160, 186 



Outcomes 8, 18, 61, 77, 104, 

106, 125, 160, 182, 184, 186 

Outlier pool, 2 percent 56, 88 

Out-of-pocket catastrophic 

costs 94 

Outpatient 6 

Outreach 189 

P 

Part B capitation 85 

Partial capitation 37, 42, 57, 166 

Participating heart bypass 

center 68, 69, 70 

Partnership 133 

Patient assessment 59, 62, 63, 72, 73, 

74,79 
Patient classification systems.... 48, 61 

Patient satisfaction 8 

Patterns of care 184 

Payment, global 67, 68, 69, 70 

Payment methods 51, 62, 87 

Payments 3, 6, 20, 30, 37 

Performance contracts 1 60 

Personal Responsibility and 

Work Opportunity Reconciliation 

Act of 1996(PRWORA).... 72, 142, 143 

Pharmacy 4, 8, 14, 75, 87 

Physically and cognitively 

impaired 161 

Physician fee schedule 87 

Physician hospital 

organizations 75 

Physician incentives 44 

Physician payment 26, 33, 39, 44, 45, 

46,48,64,76,77,84, 184 

Physician payment methods 83 

Physician payment reform 34 

Physician practice costs 44, 45, 46, 60, 88 

Physician profiling 44, 64 

Pneumococcal 2 

Post-acute care 24, 28, 38, 92 

Post-partum 7, 13 

Practice patterns 35, 183 

Pre-admission screening 

programs 17 

Preferred provider 

organizations 58 



214 



Topical Index 



Pregnant women and 

"children eligibility 7. 115. 126. 162 

Prenatal care 136 

Prescription drugs 4, 6. 8. 75. 14. 23. 

29. 87. 180 

Preventive care 7. 99. 103. 146. 181 

Pricing 66 

Pricing, all-inclusive 67. 68. 69. 70 

Primary care 172 

Primary care physician/case 

management (PCP CM) 145 

Programming 2 

PACE 59. 61. 77. 145, 

146, 148. 149. 150. 151. 152. 153. 154. 155, 

156. 157. 158 
Prospective payment 24. 39. 41. 46, 

47. 55. 56, 57. 59. 62. 63. 72, 73, 74, 75, 79. 

84. 85. 89 
Prospective payment system 

exemption 47 

Prostate cancer 107 

Provider information 190 

Provider performance 44. 56 

Provider profiles 184 

Provider sponsored 

organization (PSO) 71 

Publishing, graphics, and 

dissemination 28 

Q 

Quality assurance 5.46.61. 160. 169 

Quality improvement 5, 77 

Quality monitoring 24, 59. 62, 63, 72. 

73, 74, 84. 85 

Quality of care 6. 8. 14. 27, 31, 

104. 138 

R 

Race 138/176. 181 

Rare and expensive case 

management (RECM) 129 

Ratesetting 132 

Reform 16. 170. 171. 

172, 174, 

Regional home health 25 

Regional networks 128 

Rehabilitation 38. 55, 89 

Reinsurance 37. 49 



Relative value scale 45, 46, 60, 82, 88 

Report cards 186 

ResDAC 189 

Research 190, 191, 

Research network 103, 181 

Resident assessment 84, 85 

Residential services 98, 141 

Resource status 107 

Resource utilization 41 

Respite care 112 

Risk adjustment 37. 42. 48, 49. 50, 

54, 56, 57, 71, 78, 79, 80, 81, 82, 86, 88. 163 

Risk sharing 85 

Rural health care 128. 135, 170. 171. 

172, 174 

Rural health care transition 163, 164 

Rural health clinics 113 

Rural partners 145 

Rural primary care hospital 11. 108, 109. 110, 

111 

S 

School attendance 91 

Screening 107, 181 

Selection bias 31 

Selectivity effect 87 

Self-help group model 146 

Service substitution 5 

Sexually transmitted diseases.... 141 

Skilled nursing facility 6. 79 

Social health maintenance 

organization 80, 81. 165, 166 

Social services 165, 166 

Socioeconomic status 138 

Special populations 182 

Spending targets 44 

Spillover effect 31 

Staff time measurement 79 

State Medicaid reform 

demonstrations 118, 162 

Structured implicit review 61 

Subacute 64 

Substance abuse 115 

Subvention 89 

SSI 11. 95. 116, 129, 

140, 167 

Supplier costs 50 

Support. ADP 2 



Topical Index 



215 



Supported living 98 

Survey 3, 127, 140 

T 

Technical assistance 56, 174 

Technology 29 

Therapy 6, 38 

Third-party payment 4 

Total joint replacement 67 

Tracer conditions 61 

Training 174, 189 

Transitions 127 

Trends 141 

Two-parent families 91, 122 

U 

Uninsured 175, 180 

Unintended births 7 

Upper esophagogastro- 

duodenoscopy 35 

Urban community health clinic . 20, 21 

Urban hospitals 12 

Utilization 83, 103, 104, 138, 

146, 174, 176, 177, 183 

Utilization and expenditures 30 

Utilization management 8, 14,23,44 



V 

Validation study 27 

Ventilator 47 

Veteran affairs 89 

Virginia Independence 

Program (VIP) 179 

Volume and intensity control .... 64 

Volume controls 83 

Volume growth 88 

Vulnerable populations 15, 148, 182, 184, 

W 

Waiver programs 17 

Welfarereform 93,94, 100, 

125, 129, 130, 139, 147, 166, 175, 180 
Women and children 106, 125 



216 



Topical Index 



Alphabetical Index of Research and Demonstration Projects 



A Better Chance — Welfare 

Reform Project (95-068) 91 

A Comparative Analysis of Formulas 

Used by Medicaid and Private Payers to 

Reimburse Pharmacists for Outpatient 

Prescription Drugs (IM-040) 87 

A Framework of Cross-Sectional and 

Longitudinal Issues for Analysis in the 

Medicare Beneficiary Health 

Status Registry (96-060) 1 

A Longitudinal Study of the 

Determinants and Outcomes of 

Drug Utilization by People with 

HIV Disease (96-016) 209 

Access in Managed-Care Plans (95-095) 1 

Access to Medicare Physician Services (92-095) 1 

Achieving Change for Texans (96-044) 91 

Actuarial Methods for Improving Health 

Car? Financing Administration Payment to 

Risk Health Maintenance Organizations (92-022) 37 



Acute and Long-Term Care: 
Use, Costs, and Consequences 



(94-086) 92 



ADP Services Supporting Research and 

Demonstration Activities: Master Contract: 

CHD Research Associates, Inc. (96-002) 

ADP Services Supporting Research 

and Demonstration Activities: Task Order: 

CHD Research Associates, Inc. (96-049) 

ADP Services Supporting Research 

and Demonstration Activities: Task Order: 

CHD Research Associates, Inc. (96-050) 

ADP Services Supporting Research and 

Demonstration Activities: Master Contract: 

Jing Xing Health and Safety, Inc. (96-003) 

Alabama Better Access for You 

(BAY) Health Plan Demonstration 

Project for Mobile County (96-045) 

Alternative Health Risk Adjusters for 

the Medicare Risk Program (94-107) 



92 



37 



An Evaluation of the Connecticut 

General Assistance Managed 

Behavioral Health Care Pilot 

Program (96-020) 209 



Analysis of Methodological Aspects 
of the Medicare Beneficiary 
Health Status Registry 



(96-066) 



Analysis of Patterns of Payment, Users 

and Payment per User for Disabled 

Medicaid Enrollees by Age Group: Task Order: 

Jing Xing Health and Safety, Inc. (96-053) 

Analysis of Post- Acute Care and Therapy 
Services Using the Health Care Financing 
Administration Episode Database (94-046) 



Assessing the Compatibility of an All- 
Payer Ratesetting System and Managed 
Competition: The Maryland Experience (94-092) 



38 



Analysis of Sampling and Design 

Issues for the Medicare Beneficiary 

Health Status Registry (96-059) 3 

Analysis of the Validity of the 

Discretionary Component of 

Diagnostic-Cost-Group Risk Adjusters (94-072) 4 

Arizona Health Care 

Cost-Containment System (82-001) 92 

Arizona Welfare Reform: Employing 

and Moving People Off Welfare and 

Encouraging Responsibility Program 

(EMPOWER) (95-047) 93 



38 



Assessment and Redesign of Medicare 

Fee Schedule Areas (Localities) (94-002) 38 

Assessment of the Impact of 

Pharmacy Benefit Managers (95-010) 4 

Automated Control for Imaging 

Modalities (95-079) 205 



Availability and Effective Use of Pediatric 

and Family Nurse Practitioners under 

State Medicaid Programs (94-052) 



93 



B 

Beneficiary Information, Education 

and Marketing Strategy (95-057) 185 

Breast Cancer Treatment Initiative (IM-031) 190 

Bundle Payment for Physician and 

Hospital Services Using 

Telemedicine Services (94-065) 39 

Bundling Physician Services (92-030) 39 



Alphabetical Index of Research and Demonstration Projects 



217 



Business Health Care 

Purchasing Coalitions (94-091) 40 



California Welfare Reform: Assistance 

Payments Demonstration Project (93-005) 94 

California Welfare Reform: California 

Work Pays Demonstration Project (96-065) 94 

Cancer Retreatment Rate after Radical 

Prostatectomy in Patients Diagnosed with 

Clinically Localized Prostate Cancer (IM-057) 28 

Case-Mix Adjustment for a 

National Home Health 

Prospective Payment System (96-057) 41 

Case Studies of Medicaid 

Estate Planning (93-089) 41 

Catastrophic Costs and 

Medicaid Spenddown (93-090) 94 

Catastrophic Costs of Long-Term Care 

for Elderly Americans (92-098) 41 

Changes in Population Characteristics 

and Medicaid Utilization/Expenditures 

Among Children and Adolescent 

Supplemental Security Income 

Recipients (94-077) 95 

Changing Roles of Nursing Homes (94-083) 95 

Characteristics and Outcomes of 

Persons Screened into 

Connecticut's 2176 Program (92-093) 4 

Childhood Injuries in the Medicaid 

Population (IM-059) 181 

Collect Malpractice Insurance 

Premium Rate Information (94-008) 41 

Colorado Welfare Reform: 

Personal Responsibility and 

Employment Program (94-071) 96 

Combining Formal and Informal Care 

in Serving Frail Elderly People (92-092) 5 

Community Nursing Organization 

Demonstration External Quality 

Assurance (94-038) 5 

Community Nursing Organization 

Demonstration: Carle Clinic 

Association (92-070) 97 

Community Nursing Organization 
Demonstration: Carondelet Health 
Services, Inc. (92-071) 97 



Community Nursing Organization 

Demonstration: Living at Home/ 

Block Nurse Program (92-072) 42 

Community Nursing Organization 

Demonstration: Visiting Nurse 

Service of New York (92-073) 98 

Community-Supported Living 

Arrangements Program: 

Process Evaluation (93-077) 98 

Comparative Study of the Use of Early 

and Periodic Screening, Detection, and 

Treatment and Other Preventive and 

Curative Health Care Services by 

Children Enrolled in Medicaid (92-058) 99 

Comparison of Concurrent DCG Models 

and Partial Capitation as Payment 

Alternatives for Managed-Care 

Organizations (96-038) 42 

Comparison of Enrollment Characteristics, 

Utilization and Expenditures for Medicaid 

and Federal Employees Blue Cross Blue 

Shield Populations: Task Order: 

Jing Xing Health and Safety Inc. (96-05 1 ) 6 



Comparison of Income Information on 
1990 Census with Information Collected 
by the Current Beneficiary Survey 

Comparison of Pharmaceutical Quality 
of Care for Pediatric Asthma Across 
Medicaid Populations: Task Order: 



(95-025) 100 



University of Alabama at Birmingham 


(96-011) 


6 


Computerizing the Reports 






of Interpretive Tests 


(95-084) 


205 


Congestive Heart Failure 






Outreach Project 


(94-108) 


43 


Connecticut Welfare Reform: 






Reach for Jobs First 


(94-069) 


100 


Conversion 2000 


(95-077) 


205 


Consumer Protection and Private 






Long-Term-Care Insurance: Key Issues 






for Private Long-Term-Care Insurance 


(93-091) 


43 


Coordinating Care for Pregnant Substance 




Abusers Demonstration: Maryland 


(91-088) 


100 


Coordinating Care for Pregnant Substance 




Abusers Demonstration: Massachusetts 


(91-087) 


101 



Coordinating Care for Pregnant Substance 

Abusers Demonstration: New York (91-086) 101 



Coordinating Care for Pregnant Substance 
Abusers Demonstration: South Carolina (91-085) 



102 



218 



Alphabetical Index of Research and Demonstration Projects 



Coordinating Care Pregnant Substance 

Abusers Demonstration: Washington (91-096) 102 

Cost-Containment Measures for 

Physician and Other Services (92-045) 44 

Costs of Medicare Skilled Nursing 

Facility Therapy Services (93-092) 6 

D 

Data Collection and Analysis for 

Generating Procedure Specific Practice 

Expense Estimates (95-014) 44 

Data for Hospital Cost Monitoring 

and Analysis of Hospital Costs (92-007) 6 

Data Support Activities (IM-022) 28 

Data Users' Conference for 
Historically Black Colleges 
and Universities (95-075) 103 

Database Development (IM-021) 190 

Demonstration of Integrated Care 

Management Systems for High-Cost/ 

High-Risk Medicaid Beneficiaries (95-061) 7 

Demonstration of Managed Care Under 

Medicare Using Volume Performance 

Standards Organizations (94-097) 44 

Demonstration Project for Family 

Planning and Preventive Reproductive 

Services, State of Maryland (96-004) 7 

Demonstration Project for Preventive 

and Primary Pediatric Care: Maryland (93-079) 103 

Derivation of Relative Values for Practice 

Expenses Using Extant Data: HERI (95-012) 45 

Derivation of Relative Values for Practice 

Expenses Using Extant Data: 

Rand Corporation (95-013) 46 

Design and Evaluation of a Prospective 

Payment System for Ambulatory Care (91-073) 46 

Design and Implementation of Medicare 

Home Health Quality Assurance 

Demonstration (94-074) 46 

Design Contract for the Medicare 

Beneficiary Health Status Registry (95-026) 

Design of a Cost-Effectiveness Protocol 

for the Morbidity and Mortality in 

Hemodialysis Clinical Trials ' (94-088) 104 



Design of Specialized Protocol 
Software to Monitor Health Care 
and Case Management Data 



(95-080) 206 



Determining the Appropriateness of 
Reclassifying a Ventilator-Dependent Unit 
as a Rehabilitation Unit for Purposes of 
Reimbursement: Pennsylvania (90-070) 

Determinants of Barriers to Minority 
Access to Health Care and Differential 
Health Care Utilization Between 
Older African Americans and 
Caucasians 



47 



Determinants of Home Health Use 

Developing Cost Control Policies for 
Medicare Outpatient Services 

Development Activities of the 
HBCU Network 



(96-069) 
(IM-034) 



104 

28 



(91-075) 47 
(IM-048) 181 



Development and Testing of Risk Adjusters 

Using Medicare Inpatient and Ambulatory 

Data (93-046) 



48 



Development of a Comprehensive 

Monitoring and Evaluation Initiative 

for HCFA Programs (96-067) 8 

Development of a Global Quality 

Assessment Tool for Managed Care (94-075) 8 

Development of a Physician Prospective 

Payment System for Ambulatory Care (94- 111) 48 

Development of a Risk- Adjustment System 

under Health Reform: Lewin/VHI, Inc. (94- 101) 49 

Development of a Risk-Adjustment System 

under Health Reform: Rand Corporation (94-016) 49 

Development of Global Risk 

Assessment Models (94-117) 49 

Development of Outcome-Based 
Quality Assurance Measures for 
Small, Integrated Services Settings (94-023) 104 

Dialysis Modality Selection Among 

Patients Attending Freestanding 

Dialysis Facilities (IM-067) 181 

Dialyzer Reuse: A Cohort Study (92-0 18) 105 

Diamond State Health Plan (95-051) 105 

Disenrollment and Selection 

Experience under the Medicare 

HMO Risk Program: Task Order: 

University of Minnesota (96-039) 50 



Alphabetical Index of Research and Demonstration Projects 



219 



Disenrollment of Medicare Cancer 

Patients from HMOs (IM-050) 29 

Do the Elderly Respond Differently 

Than the Non-Elderly to Price and 

Quality Information When Choosing 

Between Health Plans? (96-012) 209 

Drug Patent Expirations and the 

Speed of Generic Entry (IM-038) 29 

Drug-Utilization-Review 

Evaluation Contract (93-033) 8 

Durable Medical Equipment Supplier 

Product and Cost Study (95-019) 50 



Early, Periodic Screening, Diagnosis 

and Treatment (EPSDT) Program 

Trend Analysis (IM-060) 181 

Economic and Cost-Effectiveness 

Studies for the U. S. Renal Data System (93-061 ) 106 

Effects of Expanded Medicaid Coverage 

of Pregnant Women (92-025) 106 

Effects of Geographic Variations on 

Medicare Capitation Rates for the Social 

Health Maintenance Organization, 

Program for All-Inclusive Care for the 

Elderly, and Community Nursing 

Organization Projects (93-093) 51 

Effects of Health Education on the 

Participation of African-American Men 

in Routine Screening for Prostate Cancer 

in Rural Southwest Mississippi (96-070) 107 



Effects of Information and Consumer 
Knowledge on Choice of Health Plans 



(94-099) 185 



Effects of Insurance on Medical Spending 

Growth and the Determinants of 

Insurance Coverage (IM-042) 29 

Effects of State Medicaid Policies 

on the Risk of Nursing Home 

Admission and Length of Stay (96-019) 209 

Effects of Telemedicine on Accessibility, 

Quality, and Cost of Health Care (94-063 ) 5 1 

Elderly Wealth and Savings: 

Implications for Long-Term Care (91-097) 107 

End Stage Renal Disease Annual 

Research Report (IM-004) 182 

End Stage Renal Disease 

Research Studies (92-021) 107 



Enrollment and Utilization Across 
Medicare Supplemental Plans 

ESRD Managed-Care Demonstration: 
Health Options 

ESRD Managed-Care Demonstration: 
Kaiser Foundation Health Plan, 
Southern California 

ESRD Managed-Care Demonstration: 
PacifiCare of California 

ESRD Managed-Care Demonstration: 
Phoenix Healthcare of Tennessee 

Essential Access Community Hospital/ 
Rural Primary Care Hospital Program: 
California 

Essential Access Community Hospital/ 
Rural Primary Care Hospital Program: 
Colorado 

Essential Access Community Hospital/ 
Rural Primary Care Hospital Program: 
Kansas 

Essential Access Community Hospital/ 
Rural Primary Care Hospital Program: 
New York 

Essential Access Community Hospital/ 
Rural Primary Care Hospital Program: 
North Carolina 

Essential Access Community Hospital/ 
Rural Primary Care Hospital Program: 
South Dakota 

Essential Access Community Hospital/ 
Rural Primary Care Hospital Program: 
West Virginia 



(94-100) 


51 


(96-083) 


52 


(96-084) 


53 


(96-085) 


53 


(96-086) 


54 



(91-089) 108 



(91-090) 108 



(91-091) 109 



(91-092) 109 



(91-093) 110 



(91-094) 111 



(91-095) 11 



Estimating Mammography Utilization 

by Elderly Medicare Women for Whom 

the Health Care Financing Administration 

Does Not Receive Administrative Claims (94-1 18) 9 

Evaluating Alternative Risk Adjusters 

for Medicare (94-106) 54 

Evaluating Methods of Estimating 

Hospital Efficiency (94-017) 9 

Evaluating the Effects of Physician 

Payment Reform on Access: Time-Series 

Analyses of Hospitalizations for 

Ambulatory Care-Sensitive Conditions (IM-055) 29 



Evaluation and Technical Assistance 
of the Medicare Alzheimer's 
Disease Demonstration 



(95-073) 112 



220 



Alphabetical Index of Research and Demonstration Projects 



Evaluation of Case Classification 

Systems and Design of a Prospective 

Payment Model for Inpatient 

Rehabilitation (95-004) 55 

Evaluation of Clinical and 

Educational Services to Rural Hospitals 

via Fiber-Optic Cable (93-074) 112 

Evaluation of Cost HMOs and Health 

Care Prepayment Plans (93-075) 55 

Evaluation of Group-Specific Volume 

Performance Standards Demonstration: 

Task Order: Health Economics 

Research, Inc. (96-081) 56 

Evaluation of HCFA Online (96-055) 186 

Evaluation of HMO Outlier 

Demonstration (95-006) 56 

Evaluation of Medicaid Managed- 
Care Programs with 1915(b) Waivers (93-073) 1 12 

Evaluation of Medicare SELECT (93-031) 10 

Evaluation of Phase II of the Home 

Health Agency Prospective 

Payment Demonstration (94-082) '56 

Evaluation of Rural Health Clinics (95-058) 113 

Evaluation of the Arizona Health 

Care Cost-Containment System (89-033) 113 

Evaluation of the Community Nursing 

Organization Demonstration (92-068) 57 

Evaluation of the Cost Effectiveness 

of Medicare Coverage of 

Influenza Vaccine (90-006) 114 

Evaluation of the Demonstration for 

Improving Access to Care for Pregnant 

Substance Abusers (92-069) 115 

Evaluation of the Diamond State 

Health Plan (95-028) 115 

Evaluation of the District of Columbia's 

Demonstration Project: Managed Care 

System for Disabled and Special 

Needs Children (96-076) 1 1 

Evaluation of the Effectiveness of the 

Operation Restore Trust Demonstration (95-003) 1 1 

Evaluation of the Essential Access 

Community Hospital/Rural Primary 

Care Hospital Program (91-078) 11 



Evaluation of the Home Health 

Prospective Payment Demonstration (90-065) 57 

Evaluation of the Impact of Health 

Plan Report Cards on Consumer 

Knowledge, Attitudes, and Choice 

in a Managed Competition Setting (95-00 1 ) 186 

Evaluation of the Iowa 

Implementation of Ambulatory 

Patient Groups (APGs) (95-015) 12 

Evaluation of the Maryland Access to 

Care Demonstration: Managed Care 

for Medicaid Recipients (92-024) 1 1 6 

Evaluation of the Medicaid 

Extension Demonstrations (91-015) 116 

Evaluation of the Medicaid 

Uninsured Demonstrations (92-064) 117 

Evaluation of the Medicare Case- 
Management Demonstrations (93-056) 58 

Evaluation of the Medicare 

Choice Demonstration (95-018) 58 

Evaluation of the Nursing Home 

Case-Mix and Quality Demonstration (94-081) 59 

Evaluation of the Oregon 

Medicaid Demonstration (94-127) 117 

Evaluation for the Program for 

All-Inclusive Care for the 

Elderly Demonstration (91-017) 59 



Evaluation of the State Medicaid 
Reform Demonstrations: 
Mathematica Policy Research, Inc. 



(94-126) 118 
118 



Evaluation of the State Medicaid 

Reform Demonstrations: Urban Institute (95-052) 



Evaluation of the Utah Prepaid 
Mental Health Plan: Coordinated 
Care Systems as Alternatives to 
Traditional Fee for Service 



(92-037) 119 



Examination of Alternative Methods for 
Calculating Relative Values for Practice 
Expenses: University of Minnesota (93-050) 



60 



Examination of the Medicaid 

Expansions for Children (93-076) 119 

Expanded Cross-Cutting Evaluation 
of Medicare Prevention Demonstrations 
under the Consolidated Omnibus Budget 
Reconciliation Act (93-002) 120 



Alphabetical Index of Research and Demonstration Projects 



221 



Expansion of the Medicare 

Current Beneficiary Survey (96-061) 12 

Exploratory Study of the Effects of 
Managed Care on Urban Hospitals: 
ANASYS (95-070) 13 

Extension of Medicaid Benefits 

for Post-Partum Women (94- 1 05 ) 13 

External Assessment of Quality 

Assurance in the Program for 

All-inclusive Care for the Elderly (93-069) 61 



Federally Qualified Health Centers (93-070) 121 

Financing of Acquired Immunodeficiency 

Syndrome and Acquired Immunodeficiency 

Syndrome-Related Complex Treatment 

Costs by Medicaid and Medicare (90-0 18) 120 

Financial Ratios: Implications for 

Assessment of Hospital Profitability 

and Efficiency (IM-005) 30 

Florida Health Security (FHS) (94- 125) 122 

Florida Welfare Reform: 

Family Transition Program (94-068) 122 

Functional Diversity in Health 
service Provision: Community 
Mental Health Center Choice (96-017) 209 



Graduate Medical Education Studies (IM-069) 87 

H 

Hawaii Quest (93-062) 123 

HCFA On-line: Market Research for 

Beneficiaries (96-080) 187 

HCFA Online: Market Research for 

Providers and Other Payers (96-005) 187 

Health Care Service Use and 

Expenditures of the 

Noninstitutionalized Population (93-095) 124 

Health Services Research Activities — 

Technical Assistance, Research, 

Information, Collaboration, Networking, 

and Program Development for 

Historically Black Colleges and 

Universities (HBCUs) (96-087) 124 

Home Care Quality Studies (90-011) 14 



Hospital Obstetrical Care: A Comparison 
of Quality Indicators in Medicaid 
Fee-for-Service and Medicaid 
Managed-Care Groups 



(94-039) 14 



I 



Identifying Drug Therapy Inappropriateness: 

Determining the Validity of Drug Use 

Review Screening Criteria (94-109) 



Illinois MediPlan Plus 
Demonstration 

Illinois Welfare Reform: Project Fresh 
Start: Homeless Families Stabilization 
Component 

Impact of Complicating Diseases on 
End Stage Renal Disease Outcomes 
and Costs 

Impact of Medicaid Eligibility 
Expansions and Innovative Programs 
for Maternal Health Care 

Impact of the Medicare Fee Schedule 
on Access to Physician Services 



14 



(96-006) 124 



(93-042) 125 



(92-020) 125 



(92-010) 125 



(92-031) 15 



Implementation and Evaluation of 

Ambulatory Patient Groups as an Outpatient 

Measurement and Financing Methodology 

in Maine (94-112) 61 

Implementation of the Home Health Agency 
Prospective Payment Demonstration (90-021) 62 

Implementation of the Multistate 

Nursing Home Case-Mix and 

Quality Demonstration (94-062) 62 

Improving Measurement of 

Hospital Output (94-090) 1 5 

Improving Outcomes for Low-Income 

Pregnant Women: Effects of Medicaid 

Eligibility and Alternative 

Delivery Systems (96-082) 126 

Information Needs for 

Consumer Choice (94-098) 188 

Influenza Immunization Initiative (IM-030) 190 

Interactive Computerized Program 
to Assist Medicare Beneficiaries in 
Evaluating Medigap Options (95-081) 206 

International Comparative Data 

and Analysis of Health Care 

Financing and Delivery Systems (95-056) 16 



222 



Alphabetical Index of Research and Demonstration Projects 



Interrelationship of Medical Conditions 

in the Nursing Home Population (94-045) 16 

Inventory of Projects with Special 

Focus on African Americans and 

Other Minorities (IM-047) 182 

Investigation System for Health 

Care Fraud and Abuse (95-078) 206 

Issues in Long-Term Care Policy for 
the Disabled Elderly with Cognitive 
Impairment (92-099) 126 

K 

Kentucky Health Care 

Partnership Plan Amendment (94-128) 127 

Kidney Allocation to Patients on the 

Transplant Waiting Lists: 

A Comprehensive Study (96-013) 210 



Levels and Determinants of 

Hospital Inefficiency (94-102) 16 

Long-Term-Care Case-Mix and Quality 

Technical Design Project (89-030) 63 

Long-Term-Care Program and 

Market Characteristics (92-027) 17 

Long-Term-Care Studies (Section 207) (89-034) 17 

Long-Term-Care Survey (90-056) 127 

Long-Term-Care Task Order Contract: 

Abt Associates, Inc. (96-022) 195 

Long-Term-Care Task Order Contract: 

Center for Health Policy Research (96-023 ) 195 

Long-Term-Care Task Order Contract: 

Lewin/VHI, Inc. (96-024) 195 

Long-Term-Care Task Order Contract: 

Michigan Public Health Institute (96-026) 196 

Long-Term-Care Task Order Contract: 

Research Triangle Institute (96-029) 196 

Long-Term-Care Task Order Contract: 

The MedStat Group (96-025) 196 

Long-Term-Care Task Order Contract: 

Rand Corporation (96-028) 197 

Long-Term-Care Task Order Contract: 

University of Minnesota (96-027) 197 

Longevity and Medicare Expenses (IM-006) 30 



Longitudinal Health Care Use and 

Expenditures of Disabled Persons (94-044) 127 

Longitudinal Study of Use of Early 

Preventive Services and Health 

Outcomes of a Nationally 

Representative Cohort of Children 

Born in 1988 and Followed-Up At 

Age Three (IM-072) 182 

M 

Maine Medicare Volume Performance 

Standard Demonstration Project (94-110) 64 

Maine Welfare Reform: 

Welfare to Work (96-064) 128 

MAINE-NET: Medicaid- and Medicare- 
Managed Care for the Elderly and 
Physically Disabled in Maine (94-089) 128 

Malpractice Component of the 

Medicare Economic Index (IM-008) 87 

Mammography Utilization Initiative (IM-032) 191 

Managed-Care Research and 

Demonstration Task Order Contract: 

Barents Group, LLC (95-038) 197 

Managed-Care Research and 

Demonstration Task Order Contract: 

Brandeis University (95-039) 197 

Managed-Care Research and 

Demonstration Task Order Contract: 

Health Economics Research (95-040) 198 

Managed-Care Research and 

Demonstration Task Order Contract: 

Lewin/VHI, Inc. (95-041) 198 

Managed-Care Research and 

Demonstration Task Order Contract: 

Mathematica Policy Research (95-042) 198 

Managed-Care Research and 

Demonstration Task Order Contract: 

MedStat Group (95-043) 199 

Managed-Care Research and 

Demonstration Task Order Contract: 

Rand Corporation (95-044) 199 

Managed-Care Research and 

Demonstration Task Order Contract: 

University of Minnesota (95-045) 199 

Managed-Care System for Disabled 

and Special Needs Children: 

District of Columbia (96-075) 129 



Alphabetical Index of Research and Demonstration Projects 



223 



Maryland Medicaid Section 1115 
Health Care Reform 
Demonstration Proposal 

Maryland Welfare Reform: 
Family Investment Program 

Massachusetts Welfare Reform, 1 995 

MassHealth: Massachusetts Health 
Reform Demonstration 

Maternal and Child Health Task Order 
Contract: Abt Associates, Inc. 

Maternal and Child Health Task 
Order Contract: Health Economics 
Research, Inc. 

Maternal and Child Health Task Order 
Contract: Lewin/VHI, Inc. 

Maternal and Child Health Task Order 
Contract: Mathematica Policy Research 

Maternal and Child Health Task Order 
Contract: Research Triangle Institute 

Maternal and Child Health Task Order 
Contract: Rand Corporation 

Maternal and Child Health Task Order 
Contract: University of Alabama at 
Birmingham 



(96-009) 129 



(95-048) 
(95-069) 

(95-024) 

(96-030) 

(96-032) 
(96-036) 



129 

130 

131 
200 

200 
200 



(96-033) 201 

(96-035) 201 

(96-034) 201 

(96-031) 201 



Maximizing the Cost Effectiveness of 

Home Health Care: The Influence of Service 

Volume and Integration with Other Care 

Settings on Patient Outcomes (94-087) 18 

Maximizing the Effective Use of 

Telemedicine: A Study of the Effects, 

Cost Effectiveness, and Utilization 

Patterns of Consultation via 

Telemedicine (95-023) 19 

Medicaid Analysis Project for States (90-062) 1 3 1 

Medicaid Capitation Rate Development (92-023) 132 

Medicaid Demonstration and Evaluation 

Support Projects: Master Contract: 

Mathematica Policy Research, Inc. (92-086) 19 

Medicaid Demonstration and 

Evaluation Support Projects: Master 

Contract: Research Triangle Institute (92-082) 132 

Medicaid Demonstration and 

Evaluation Support Projects: Master 

Contract: SysteMetrics/MedStat (92-084) 132 



Medicaid Demonstration Project 

for Los Angeles County (96-007) 133 

Medicaid Early, Periodic Screening, 

Diagnosis and Treatment: Task Order: 

Jing Xing Health and Safety, Inc. (96-052) 20 

Medicaid Extension of Eligibility to 

Certain Low-Income Families Not 

Otherwise Qualified to Receive Medicaid 

Benefits: Extending Medical Coverage to 

Certain Low-Income Families (91-084) 133 

Medicaid Extension of Eligibility to 

Certain Low-Income Families Not 

Otherwise Qualified to Receive 

Medicaid Benefits: South Carolina 

Health Access Plan (SCHAP) (91-083) 134 

Medicaid Managed Care and 

Avoidable Hospitalization (94-133) 134 

Medicaid Program Research to Study 

Medicaid Policy Alternatives for the 

State of New York (92-056) 135 

Medical Assistance Facility 

Demonstration Project (88-016) 135 

Medical Claims Analysis Using 

Artificial Neural Network Pattern 

Recognition Methods (95-083) 207 

Medical Savings Accounts for 

Medicare Beneficiaries (IM-066) 87 

Medicare Ambulatory and Coordinated 

Care Demonstration Projects: Master 

Contract: Abt Associates, Inc. (92-081) 64 

Medicare Ambulatory and Coordinated 

Care Demonstration Projects: Master 

Contract: Brandeis University (94-095) 193 

Medicare Ambulatory and Coordinated Care 

Demonstration Projects: Master Contract: 

Health Economics Research, Inc. (92-080) 65 

Medicare Ambulatory and Coordinated Care 

Demonstration Projects: Master Contract: 

Mathematica Policy Research, Inc. (92-078) 65 



Medicare and Medicaid Statistical 
Supplement: Health Care Financing 
Review 



(IM-001) 30 



Medicare Beneficiaries Receiving Chronic 

Renal Dialysis Not Identified as Having 

End Stage Renal Disease (93-064) 136 

Medicare Catastrophic Coverage 

Act (MCCA) Evaluation: Beneficiary and 

Program Impact (89-032) 136 



224 



Alphabetical Index of Research and Demonstration Projects 



Medicare Catastrophic Coverage Act 

Evaluation: Impact on Industry (89-028) 137 



Medicare Competitive 
Pricing Demonstrations 

Medicare Coordinated 
Open Enrollment 



(95-017) 66 
(96-010) 188 



Medicare-Designated Cataract Surgery 

Providers: Cataract Eye Center of 

Cleveland, Inc. (93-084) 66 

Medicare-Designated Cataract Surgery 

Providers: National Medical Enterprises (93-081) 66 

Medicare-Designated Cataract Surgery 

Providers: Southwestern Eye Center, Ltd. (93-083) 67 

Medicare End Stage Renal Disease 

(ESRD) Captitation Demonstration: 

Technical Assistance Contract (94-103) 67 

Medicare HMO Evaluation (IM-037) 3 1 

Medicare Institutional/Facility-Based 

Services Demonstration Projects: Master 

Contract: Mathematica Policy 

Research, Inc. (92-076) 138 

Medicare Negotiated Bundled Payment 
Demonstrations: Design and Solicitation (95-050) 67 

Medicare Participating Heart Bypass 

Center Demonstration: Georgia (91-006) 68 

Medicare Participating Heart Bypass 

Center Demonstration: Indiana (93-011) 68 

Medicare Participating Heart Bypass 

Center Demonstration: Massachusetts (91-003) 69 

Medicare Participating Heart Bypass 

Center Demonstration: Michigan (91-004) 69 

Medicare Participating Heart Bypass 

Center Demonstration: Ohio (91-005) 69 

Medicare Participating Heart Bypass 

Center Demonstration: Texas (93-012) 70 

Medicare Participating Heart Bypass 

Center Demonstration Extended 

Evaluation (94-010) 70 

Medicare Preferred Provider 

Organization (94-011) 71 

Medicare SELECT Demonstration 

Program Evaluation: Report 

to Congress (IM-036) 3 1 

Mental Health Service Utilization by 
the Elderly in Tenneessee: The Effect 
of Race, Social Class, and Comorbidity (96-073) 138 



Midwest Rural Telemedicine Consortium: 

A Pilot Demonstration Project (94-066) 71 

Minnesota Prepaid Medical Assistance 

Project Plus (PMAP+) (95-029) 139 

Minnesota's Work First 

Demonstration (96-042) 139 

Mississippi New Direction Welfare 

Reform Demonstration Project: 

Amendment (96-046) 72 

Modeling Case Manager's Care 

Planning Decisions for Community 

Dwelling Disabled Elders in Medicaid 

HCBS Waiver Programs (96-018) 210 

Monitoring Access to Physician Services 

Among Vulnerable Subgroups of the 

Medicare Population: Controlling for 

the Underlying Need for Services (IM-053) 3 1 

Monitoring and Evaluation of the 

Medicare Cataract Surgery Alternate 

Payment Demonstration (94-130) 72 

Monitoring Changes in Self-Reported 

Access to Care Among Medicare 

Beneficiaries (IM-052) 32 

Monitoring Needs Not Met by Medicare: 

An Examination of the Use of Non-Covered 

Services Among Medicare Beneficiaries (IM-054) 32 

Monitoring Utilization of and Access to 

Services for Medicare Beneficiaries Under 

Physician Payment Reform (IM-010) 32 



Montana Welfare Reform: 
Families Achieving Independence 
in Montana (FAIM) 



(95-049) 139 



Multistate Analysis of Utilization, 

Expenditures, and Access to Care for 

Persons with Acquired Immunodeficiency 

Syndrome (94-073) 140 

Multistate and Longitudinal Cohorts of 

Medicaid Children: Patterns of Enrollment, 

Utilization and Expenditures: Task Order: 

Jing Xing Health and Safety, Inc. (96-054) 20 

Multistate Nursing Home Case-Mix 

and Quality Demonstration: Kansas (89-054) 72 

Multistate Nursiing Home Case-Mix 

and Quality Demonstration: Maine (89-055) 73 

Multistate Nursing Home Case-Mix 

and Quality Demonstration: Mississippi (89-056) 73 

Multistate Nursing Home Case-Mix and 

Quality Demonstration: South Dakota (89-057) 74 



Alphabetical Index of Research and Demonstration Projects 



225 



Municipal Health Services Program: 

Baltimore, Maryland (79-001) 20 

Municipal Health Services Program: 

Cincinnati, Ohio (79-003) 21 

Muncipal Health Services Program: 

Milwaukee, Wisconsin (79-004) 21 

Municipal Health Services Program: 

San Jose, California (79-002) 22 

N 

National Health Interview Survey 

Disability Supplement: 1994-95 (93-048) 140 

National Minority Historically Black 

Colleges and Universities Health 

Education Initiative (94-114) 141 

National Recurring Data Set Project: 

Ongoing National State-by-State Data 

Collection and Policy/Impact Analysis 

on Residential Services for Persons 

with Developmental Disabilities (94-113) 141 

Nebraska Welfare Reform 

Demonstration Project (95-062) 142 

New Hampshire Employment Program (96-047) 142 

New Hope Project (96-048) 143 

New Jersey Welfare Reform: 

Family Development Program (92-041) 143 

New York Case-Mix Payment and 

Quality Demonstration (90-019) 74 

Non-Response Bias in the Medicare 

Beneficiary Health Status Registry (IM-056) 33 

Nursing Home Payments by Source: 

Preliminary Statistics from the 

Medicare Current Beneficiary Survey (92-094) 22 

O 

Oakland's Enhanced Enterprise 

Community-Community Building 

Team Program (96-040) 143 

OhioCare (95-027) 144 

Oklahoma SoonerCare Demonstration (96-008) 145 

On Lok's Risk-Based Community Care 

Organization for Dependent Adults: 

California Department of Health Services (84-008) 145 



Online Information, Counseling, 

and Assistance Program Reporting 

and Telecommunicaitons System (95-072) 207 

Oral Rehydration Therapy and 

Children Immunization Initiatives for 

Infants and Children of AFDC 

Beneficiaries from Inner-City 

African-American Communities (96-072) 146 

Oregon Reform Demonstration (93-038) 147 

Organizational Double Agents: 
Agency and Institutionalism in 
Medical Group Governance (96-021) 210 

Outlier Pool Demonstration (IM-058) 88 



Patient Record System for Managing 
and Monitoring Health Care Delivery 
and Outcome 

Patterns and Outcomes of Cancer 
Care in the Medicare Population 

Patterns of Use and Payments for 
Disabled Medicaid Enrollees 



(95-053) 207 
(IM-012) 183 
(IM-061) 183 



On Lok's Risk-Based Community Care 
Organization for Dependent Adults: 
On Lok Senior Health Services 



Patterns of Utilization and Expenditures 

for Prescription Drugs in Selected State 

Medicaid Programs (94-005) 23 

Payment of Pharmacists for 

Cognitive Services (92-057) 75 

Pennsylvania Welfare Reform: 

Pennsylvania Pathways to 

Independence (95-065) 147 

Per Case Payment to Encourage Risk 
Management and Service Integration 
in the Inpatient Acute-Care Setting (95-055) 75 

Persons With Acquired Immunodeficiency 

Syndrome in the Medicare Program (IM-068) 183 

Phase II Implementation of the Home 

Health Agency (HHA) Prospective 

Payment Demonstration (95-076) 75 

Physician Behavioral Response to 

Fee Changes (IM-043) 33 

Physician Capitation for Medicare 

Services: Feasibility Study and 

Demonstration Design (94-093) 76 

Physician Practices' Responses to 

Changes in Fees (IM-041) 88 



(84-001) 146 



226 



Alphabetical Index of Research and Demonstration Projects 



Policy Study of the Cost Effectiveness 

of Institutional Subacute Care Alternatives 

and Services: 1984-92 (90-017) 76 



Potential of Coordinated Care 
Targeted to Medicare Beneficiaries 
with Medicaid Coverage 



(92-100) 148 



Predictors of Access and Effects of 

Medicare Post-Hospital Care for 

Beneficiaries 65 Years of Age and Over (94-085) 24 

Preparing Medicare Consumers for 

Selecting and Utilizing Managed 

Care Plans (95-054) 208 

Prescription Drug Utilization and 

Expenditures in Medicare (IM-064) 33 

Prior Mammography Use: Does It 

Explain Black/White Differences 

in Breast Cancer (96-015) 210 

Program for All-inclusive Care for the 

Elderly (PACE) Quality Assurance (96-056) 77 

Program for All-inclusive Care for the 

Elderly: Beth Abraham Hospital (90-003) 148 

Program for All-inclusive Care for the 

Elderly: Bienvivir Senior Health Services (92-005) 148 

Program for All-inclusive Care for the 

Elderly: California Department of 

Health Services (95-092) 149 

Program for All-inclusive Care for the 

Elderly: Center for Elders' Independence (95-093) 150 

Program for All-inclusive Care for the 

Elderly: Colorado Department of 

Social Services (91-066) 150 

Program for All-Inclusive Care for the 

Elderly: Community Care Organization (90-045) 151 

Program for All-inclusive Care for the 

Elderly Data Management, 1992-95 (92-101) 151 

Program for All-inclusive Care for the 

Elderly Data Management, 1995-98 (95-059) 151 

Program for All-inclusive Care for the 

Elderly: East Boston Geriatric 

Services, Inc. (90-010) 152 

Program for All-inclusive Care for the 

Elderly: Massachusetts State Department 

of Public Welfare (90-009) 152 

Program for All-inclusive Care for the 

Elderly: New York State Department of 

Services, March 1992-March 1995 (92-033) 153 



Program for All-inclusive Care for the Elderly: 

New York State Department of Social 

Services, October 1989-January 1995 (90-004) 154 

Program for All-inclusive Care for the 

Elderly: Oregon State Department of 

Human Services (90-007) 154 

Program for All-inclusive Care for the 

Elderly: Providence Medical Center (90-008) 155 

Program for All-Inclusive Care for the 

Elderly: Richland Memorial Hospital (90-043) 155 

Program for All-inclusive Care for the 

Elderly: Rochester General Hospital (92-032) 156 

Program for All-Inclusive Care for the 

Elderly: South Carolina State Health and 

Human Services Finance Commission (90-044) 156 

Program for All-inclusive Care for the 

Elderly: Sutter Health System (94-040) 157 

Program for All-inclusive Care for the 

Elderly: Texas Department of 

Human Services (92-006) 157 

Program for All-inclusive Care for the 

Elderly: Total Longterm Care, Inc. (91-065) 158 

Program for All-inclusive Care for the 

Elderly: Wisconsin State Department of 

Health and Social Services (90-046) 158 



Program Information Inquiries 



(IM-020) 191 



Program of Preconceptional Intervention 

for Women At Risk for Low-Birth- Weight 

(LBW) Infants: State of Florida (92-029) 159 



Program Payments and Utilization 
Trends for Medicare Beneficiaries 
with Disabilities 



(93-094) 159 



Project Demonstrating and Evaluating 

Alternative Methods to Assure and 

Enhance the Quality of Long-Term Care 

Services for Persons with Developmental 

Disabilities through Performance-Based 

Contracts with Service Providers (94-096) 160 

Prospective Per Case Payment for 

Episodes of Hospital Care (93-051) 77 

Prostate Cancer Care and Outcomes 

Among Medicare Beneficiaries (IM-045) 33 

Prostate Disease Information 

Initiative (IM-033) 191 



Alphabetical Index of Research and Demonstration Projects 



227 



Quality Assurance for Phase II of the 

Home Health Agency Prospective 

Payment Demonstration (95-094) 

Quality of Care: Medicaid and 

Other Populations (94-006) 



24 



25 



R 

Racial and Payer Differences in Infant 

Mortality in a National Sample of 

Preschool Children (IM-071) 184 

Randomized Controlled Trial of Expanded 

Medical Care in Nursing Homes for Acute 

Care Episodes: Monroe County Longterm 

Care Program, Inc. (92-034) 78 

Randomized Controlled Trial of 

Primary and Consumer-Directed Care 

for Persons with Chronic Illnesses (94- 131) 161 

Refinements to Medicare DCG Risk- 
Adjustment Models: Task Order: 
Health Economics Research, Inc. (96-037) 78 

Regional Variation in Home Health 

Episode Length and Number of 

Visits Per Episode (93-097) 25 

Rehabilitating Medicare Beneficiaries 

at Home (93-035) 161 

Rehabilitation Facilities and Units: 

Utilization, Cost, and Payment (IM-024) 89 

Research and Demonstration Task Order 

Contract: Abt Associates, Inc. (95-030) 202 

Research and Demonstration Task Order 

Contract: Barents Group, LLC (95-031) 202 

Research and Demonstration Task Order 

Contract: Brandeis University (95-032) 202 

Research and Demonstration Task 
Order Contract: Health Economics 
Research, Inc. (95-033) 203 

Research and Demonstration Task Order 

Contract: Lewin/VHI, Inc. (95-034) 203 

Research and Demonstration Task Order 

Contract: Rand Corporation (95-035) 203 

Research and Demonstration Task Order 

Contract: Urban Institute (95-037) 204 

Research and Demonstration Task Order 

Contract: University of Wisconsin (95-036) 204 



Research Centers: Master Contract: 
Health Economics Research, Inc. 

Research Centers: Master Contract: 
Lewin/VHI, Inc. 

Research Centers: Master Contract: 
Rand Corporation 

Research Centers: Master Contract: 
University of Minnesota 

Research Data Assistance Center 
(ResDAC): Master Contract: 
University of Minnesota 

Research Data Assistance Center 
(ResDAC): Task Order: University 
of Minnesota 

Rhode Island Long-Term Care Waiver: 



(92-087) 


193 


(92-088) 


193 


(92-090) 


194 


(92-089) 


194 



(96-001) 189 



(96-062) 189 



CHOICES 


(95-067) 


162 


Rhode Island Rite Care 


(94-104) 


162 


Risk Adjustment for Medicaid 






Recipients with Disabilities 


(96-058) 


79 


Risk Adjustment of Payment for 






Mental Health and Substance Abuse 


(94-124) 


163 


Risk-Adjusted Payment Models for 






the Non-Elderly 


(94-122) 


79 


RUG III Validation for National Skilled 






Nursing Facility (SNF) Payment System 


(96-078) 


79 


Rural Health Care Transition 






Grant Evaluation 


(94-121) 


163 


Rural Health Care Transition 






Grants Program 


(89-029) 


164 



Second Generation Social Health 

Maintenance Organization 

Demonstration: California (95-085) 80 

Second Generation of Social Health 

Maintenance Organization 

Demonstration: Colorado (95-090) 80 

Second Generation of Social Health 

Maintenance Organization 

Demonstration: Florida (95-091) 80 

Second Generation Social Health 

Maintenance Organization 

Demonstration: Massachusetts (95-086) 81 

Second Generation Social Health 

Maintenance Organization 

Demonstration: Nevada (95-088) 81 



228 



Alphabetical Index of Research and Demonstration Projects 



Second Generation Social Health 
Maintenance Organization 
Demonstration: South Carolina 



(95-087) 81 



Second Revision of the Medicare 

Geographic Practice Cost Index (GPCI) (95-002) 82 

Site Development and Technical 

Assistance for the Second Generation 

Social Health Maintenance 

Organization Demonstrations (93-078) 82 

Social Health Maintenance Organization 

Project for Long-Term Care: 

Elderplan, Inc. (84-004) 165 

Social Health Maintenance Organization 

Project for Long-Term Care: Kaiser 

Permanente Center for Health Research (84-006) 165 

Social Health Maintenance Organization 

Project for Long-Term Care: 

SCAN Health Plan (84-007) 166 



Sources of Medicare Home Health 
Expenditure Growth: Implications for 
Control Options 

South Carolina Palmetto 
Health Initiative 

South Carolina Welfare Reform: 
Family Independence Act 

Special Care Managed-Care Initiative 

Staff- Assisted Home Dialysis 
Demonstration 

Stage of Cancer at Diagnosis for Medicare 
HMO and' Fee-for-Service Enrollees 

State-Administered Programs for Human 
Immunodeficiency Virus-Related Care 

State Health Care 
Reform Monitoring 

State of Minnesota "Senior Health 
Options (SHO) Project" 

State Primer on All-Payer Systems for 
Health Care Services 

State Response to Medicaid 
Estate Planning 



State Rural Health Network Reform 

Initiative: Assisting Washington Rural 

Communities Transition to Health 

Care Reform (94-030) 170 



(92-048) 


83 


(95-022) 


166 


(96-063) 


166 


(92-026) 


167 


(91-016) 


168 


(IM-051) 


34 


(94-123) 


168 


(95-020) 


169 


(95-089) 


169 


(93-039) 


83 


(92-102) 


170 



State Rural Health Network Reform 

Initiative: Financing Models for 

Florida's Rural Health Networks (94-025) 170 

State Rural Health Network Reform 

Initiative: Minnesota Rural Health 

Network Reform Initiative (94-026) 1 7 1 

State Rural Health Network Reform 
Initiative: Mississippi Rural Health 
Network Reform Initiative (94-027) 171 

State Rural Health Network Reform 

Initiative: Nebraska Rural Health 

Network Reform Initiative (94-028) 172 

State Rural Health Network Reform 

Initiative: North Carolina Rural Health 

Network Reform Initiative (94-029) 172